Let’s Discuss Cholesterol – Adapt Your Life® Academy



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Adapt Your Life® Academy


Let’s Discuss Cholesterol

I’m going to introduce some ideas about cholesterol and it’s probably going to be a regular feature to have live updates on cholesterol because it is on everyone’s mind. There was a really interesting paper, titled “Association of Lipid, Inflammatory, and Metabolic Biomarkers with Age at Onset for Incident Coronary Heart Disease in Women” that I’m going to try to explain to you.

The general approach to cholesterol needs to change

Thinking about cholesterol requires a paradigm shift, meaning a change in way of thinking. I know we’ve all been taught that cholesterol is bad, that “L” for LDL is “lousy” or “lethal” and “H” for HDL is “healthy”. The problem is that it’s not that simple. If it does matter, even the cholesterol as this paper shows, it’s nowhere near as important as the other things that we’re going to talk about. If LDL is an issue, it is one of the last things you want to deal with. This paper just came out, so it has not been discussed in the medical field much. It got no media recognition which is interesting, but I think that one of the reasons for that is that it’s written in a manner that doesn’t have headlines like “LDL doesn’t matter,” which is really what the paper says.

The old way to look at cholesterol was the total and LDL cholesterol. I was taught that’s how you do it but actually, as you look at cholesterol further, there’s the large LDL, small LDL, large HDL, small HDL, triglycerides, and different particle numbers and you can get advanced testing to actually show this in your own blood. As I’ve gone on, you remember I was introduced to this over 20 years ago and, yes, I had all the concerns that a lot of doctors have today when they look at it for the first time. I’ve lived through this and have examined, yes, you can go from the total, LDL, triglyceride, and HDL – four blood tests – to 20 blood tests (the “lipid subfractions,” it’s called). Then, you can go to other inflammatory markers, you can even go to measure the arteries now to see if you have the disease that the cholesterol measurements are trying to predict and trying to prevent.

Metabolic syndrome is the real issue

A lot has changed over the last 20 years. In the cholesterol masterclass we talk about metabolic syndrome being the new target, the new cause of atherosclerosis. Metabolic syndrome consists of not total cholesterol and LDL, it’s triglyceride and HDL. It goes from looking at two of the four factors in that four blood tests lipid to the other two. Metabolic syndrome also includes abdominal circumference, elevated blood pressure, and elevated blood glucose even if you’re not diagnosed with high blood pressure or diabetes. Pre-diabetes or pre-hypertension count in metabolic syndrome. A lot of doctors that you’re going to meet today have not been in the whole keto world for 22 years. Many of you have already shared your experiences of how doctors prejudged obesity or other health issues and that’s of course just terrible. It’s the last place where a doctor can still discriminate or be prejudiced and get away with it, not acknowledging that obesity is a disease and that everyone has their own story and that it’s worthy of treatment.

My background in research

I went into clinical research training and wrote my own clinical research studies. I was trained as what’s called an investigator-initiated researcher. Some researchers take studies that drug companies or other people write, and then they implement those studies, and they can call themselves researchers because they’re doing the study, implementing someone else’s study. I got trained to write my own studies, which means you have to understand how to not just read a paper, but how to write a grant, how to assess a certain number of people in the study to answer a question, and pose the question carefully in a way that makes sense, and even be cognizant of how much money it would cost to do a study.

That’s my background. That, I have to say, is pretty unique in the keto world. The other investigators who’ve done the work like me include Steve Phinney and Sarah Hallberg, who did the Virta Health Study – they wrote it, they implemented it – Jeff Volek, of course, at Ohio State. However, Jeff’s not a clinical researcher or MD; he’s a PhD in Exercise Physiology and Nutrition and doesn’t do studies on people with serious illnesses, for example. We all have our strengths in designing the research, and I think that gives me a particular ability to read literature that other people have written and also to critique them. When you listen to different doctors you want people who are able to read literature and who follow guidelines that a system wants. You have to know what the background of your source of information is. I’m pleased to be able to have given the Masterclass and to coach you and help you understand these things. Cholesterol is one of the big ones. I have to tell you, it’s a good thing we have cholesterol in our body because without it, we would not be alive.

Cholesterol is important

One day I woke up and wondered, if LDL is so bad, why is it in there? In fact, LDL cholesterol is there to carry around things like fat-soluble vitamins in a water-soluble, aqueous blood environment. Blood is water-soluble, the fats and fat-soluble vitamins and cholesterol are fat-soluble. They wouldn’t do well being carried around just by themselves without something carrying them around the aqueous bloodstream. We have cholesterol in every one of our cells. The cell walls are made of cholesterol, and years ago, I smelled a rat when it came to thinking cholesterol was bad. Your livers make twice the cholesterol that you eat, it doesn’t matter how much you eat cholesterol, your liver is going to make more. I thought to myself, if cholesterol is that bad, why is your liver making twice as much? That’s because you need it.

Medication is not the only way

I will repeat this and you’ll go to your doctors, the doctors will say, “No, here, do this, do that,” and each time I’ll try to respond, and I’ll give these chalk talks about that. I do think there is a role for statin medications. I’m not a statin basher like some of the keto folks out there who I think are trying to get attention by being more radical. I think there’s a role for medication, and it’s individualized. Rest assured with a keto lifestyle, you’re using lifestyle to treat the cholesterol, so it’s not like you’re not doing anything. In fact, it’s in the guidelines for medical doctors and how you treat cholesterol. The first thing you do is change your lifestyle. Most doctors with a fatalistic approach of, “my patients never change,” they’ll skip the lifestyle thing and go directly to medication, but it’s not the only way to approach things. That’s been my diplomatic way of approaching other organizations, other doctors, to just say, well, that’s one way to do it, here’s another way.

Article review: “Association of Lipid, Inflammatory, and Metabolic Biomarkers with Age at Onset for Incident Coronary Heart Disease in Women”

Now to the critical review of a paper. Think about trying to predict heart disease; how can we figure out if a factor is going to cause heart disease if you have someone who already has heart disease? When you try to figure out what factors caused it after someone has heart disease, it’s more difficult. One of the reasons is that often people are put on medications after they have heart attacks or heart problems, so you can never tease out whether the medications are part of it or helping it or reducing the risk. One of the best kinds of studies is based on trying to prevent the first heart attack. You take people who haven’t had a heart attack yet and where you don’t know if they have underlying heart disease or not. We’re not talking about coronary scores, we’re not talking about blood cholesterols, we’re talking about heart attacks, documented outcomes – you can’t fake those.
This paper was using medication to try to prevent that first heart attack. In fact, they used aspirin in the clinical trial and it didn’t work. The clinical trial actually is trying to prevent that first heart attack, and the beauty of that in terms of trying to find causality is you don’t have a whole lot of confounding factors. It’s like you’re getting a pure view of these risk factors. They measured things like age, blood pressure, smoking status, cholesterol levels, and diabetes levels if someone had diabetes in a group of women. “Incident coronary heart disease” refers to the first sign of a heart attack. That means you’re going to be getting a pure view without contamination or co-intervention. It gives you a pretty nice look at these individual factors to see if they were associated with the illness. It’s better than a retrospective article or a cohort analysis observational. It was a randomized trial. That also means that they were taking care of the data in a sophisticated manner. Some studies are really well-funded to be able to follow people really well, even collect the measures twice. Other studies are not well-funded or well-designed to double measure things and the researchers might just ask people what they eat once and then five years later ask if they’re healthy, which just isn’t very solid science. In this study, they took 28,000 women – with a couple of thousand people, you have a reasonable idea of getting statistical significance. This is 28,000 women, followed between 1993 to the year 2020. Some people had started having heart attacks. These studies are the ones that doctors value the most. It’s not just predicting whether you have a cholesterol level. It’s actually an outcome that you know you’re trying to prevent. That’s a heart attack. You see, we don’t know how to prevent heart attacks in everyone, despite what the doctors may tell you. We try to do what we can.
Think to yourself, what are the most important things that your doctor talks about in terms of preventing heart disease? I would hope they would talk about smoking, right? That’s a big factor. We’ve known for a long time that smokers are at higher risk of having a heart attack. You would think that that would come out in a paper like this. Your doctor may have talked about blood pressure, right? And yes, blood pressure that’s not treated leads to things like heart disease, strokes, and things like that. Did your doctor talk to you about weight and give you help in lowering the weight or did they just talk about the LDL cholesterol? That’s important in a study like this, they measured all these different things. Let’s find out what factors were predictive of that first heart attack in women and see what is the most important thing…

What is the highest risk factor for a heart attack in women?

It’s diabetes. Diabetes is the most powerful factor that predicts having a heart attack. You don’t want to have diabetes. Diabetes gives women 10 times the risk of having a first heart attack. Other factors that are almost as powerful as diabetes include metabolic syndrome, hypertension (which is part of metabolic syndrome), smoking, and obesity. LDL cholesterol presents no risk. HDL is a pretty big risk and that’s part of metabolic syndrome. What I like about this is the researchers had no preconceived idea of what they should expect to see, and here are the numbers.
This is a paper that shows the value of treating BMI, which is part of the Obesity Medicine Association. Treating BMI is more important than treating cholesterol in this predictive type of paper. You could argue, “You didn’t really show that in a clinical trial going forward,” but this is pretty solid evidence in a trial that was collected prospectively. Remember, it’s the things we’ve known about for a long time – smoking, blood pressure, extra weight on the body, metabolic syndrome, and diabetes. It’s not the LDL cholesterol. I know that’s what we’ve been taught and I know doctors are focusing on it. Yes, there need to be replications of this paper, but it puts in one paper what we’ve suspected for a long time, that you want the glucose level to be controlled and the insulin level to be controlled. You don’t want to have diabetes.This is one of the first papers that has compared the relative contribution of glucose and diabetes or LDL cholesterol, which is a more powerful predictor and risk factor. Hands down it’s diabetes, glucose metabolism, triglyceride, HDL, which was pretty exciting to see.Listen to the full podcast episode here.
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