I just finished reading health blogger and podcaster, Jimmy Moore's, new book called
Cholesterol Clarity: What the HDL is Wrong with My Numbers. For those interested in diving deeper into one of nutrition's most misconstrued and contentious issues, or simply want the "straight dope on cholesterol" (borrowing from the name of Peter Attia's unparalleled
blog series on the issue, which I HIGHLY recommend), this is a must read book. Not only does it provide some of the latest research and thinking on the topic through a series of interviews with 28 leading experts in the field, but Moore packages the information in an accessible way for the widest possible audience, whether you're a lipid researcher or someone who just wants to stay healthy.
So, let's dive into some the main issues in the book and some of my key takeaways.
Cholesterol is actually a good thing that plays an irreplaceable role in the body. Bottom line: if you don't have cholesterol, you die. Morbid, but true. Here are a few essential things it does or supports in the body:
- Hormone production, including estrogen, progesterone, testosterone, pregnenolone, adrenaline, cortisol, and DHEA
- The health and efficiency of cell membranes
- Nervous tissue, including the white matter in your brain
- Optimal adrenal gland function, which modulate a number of different vital hormones like adrenaline as well as kidney function
- Water and electrolyte balance
- Formation of Vitamin D
- Immune function
By far, one of the most important things influenced by cholesterol is something called coenzyme Q10, or CoQ10. Some, like Nora Gedgaudas, the author of
Primal Body, Primal Mind, have called CoQ10 the "single most important nutrient for the functioning of the heart."
When cholesterol is too low, bad things can happen. Based on the important functions listed above, you can probably guess some of the negative things that can happen in the body when cholesterol is too low. For example, cholesterol actually plays a very important role in tissue repair, specifically with stem cell production. As a result, blood vessels can become stiffer - not a good combination with small, dense LDL particles. Research has also shown a close link between low cholesterol and a higher risk of infection, cancer, and a variety of mental side effects, such as depression and a higher likelihood of suicidal behavior.
In fact, research has documented that people with the lowest cholesterol levels actually had the
highest rate of death from coronary heart disease and demonstrate a
greater risk for some cancers. In addition,
this study actually found that almost half of patients hospitalized for heart disease (80% experiencing acute symptoms), had LDL cholesterol levels less than 100 mg/dL, which is the current recommended level by the American Heart Association. As Moore argues, LDL cholesterol (and total cholesterol) are bad predictors of heart disease risk.
Dietary cholesterol doesn't really impact your numbers. The amount of cholesterol from food makes up only about 15-30 percent of your body's total cholesterol. In fact, the overwhelming majority of cholesterol our bodies use - up to 2 grams every day - is actually produced within the body itself, mostly in the liver. Cholesterol is tightly regulated by the body and as Dr. Chris Masterjohn explains in
Cholesterol Clarity, "if we eat a lot of cholesterol, our bodies make less of it; if we eat less cholesterol, our bodies make more of it. In most people, the majority of cholesterol that is circulating in the blood is made by their own bodies."
All LDL isn't "bad cholesterol." There are actually two kinds, or patterns, of LDL cholesterol. Pattern A is large and fluffy, regarded by experts as generally harmless. Pattern B, on the other hand, are potentially more dangerous since they are small and dense. Many will say that this measure of particle size and number, or LDL-P, is a much better way of determining risk, than the traditional LDL-C measure that shows up on a standard lipid panel (which is actually a calculated number, not one that's directly measured - more in the next section on this).
Thankfully, there are more and more options available to test for this. One such test is called the NMR LipoProfile test made by the relatively new diagnostic testing company in North Carolina, LipoScience. The
test uses NMR technology (which stands for nuclear magnetic resonance and is regarded as one of the best technologies on the market) to actually measure the number of LDL particles in a blood sample.
Of course, certain dietary choices can influence the ratio of Pattern A and Pattern B LDL in the blood, which Moore also flags as quite concerning. He particularly focuses in on the relatively recent trends towards promoting polyunsaturated fats, mostly in the form of vegetable oils (things like canola oil, soybean oil, etc). It is true that there is a fair bit of research showing the effectiveness of polyunsaturated fats (PUFAs) at lowering LDL in the blood. The problem is that PUFAs help achieve this reduction in LDL primarily through decreasing the number of good Pattern A LDL particles, leaving mostly Pattern B. You can see how this can be extremely concerning for heart disease and atherosclerosis risk. One of the best ways to increase the number of good Pattern A particles and decrease the number of Pattern B particles is by eating quality saturated fats from things like coconut, and grass-fed beef and butter.
LDL is actually a calculated number on your standard lipid panel.
If there is one number from the standard lipid panel that doctors focus
on, along with total cholesterol, it's LDL. The entire
statin-prescribing system, argues Moore, has been built upon
artificially defining a certain threshold for LDL and total cholesterol
(which isn't really rooted in any solid evidence as mentioned above) and teaching
physicians (very well) to automatically prescribe the drug once your
numbers exceed these thresholds. Usually any conversation about diet is
secondary or nonexistent. This is essentially how Lipitor and other statin drugs have become some of the
most commonly prescribed medication on Earth.
Among some alternatives, like
testing for LDL particle size and number, there is also pretty strong
consensus that your ratio of HDL cholesterol to triglycerides is a better gauge of
current heart health. Both numbers are on the standard lipid panel, which makes them a bit more accessible. The easiest prescription to maximize HDL while minimizing triglycerides is by avoiding carbohydrates and eating more fats.
Keeping total cholesterol low, as guidelines recommend, is 100% counter-intuitive. The prevailing guidelines by a variety of public health authorities focus exclusively on total cholesterol and LDL, and specifically keeping these two numbers low. In the case of total cholesterol, guidelines suggest this number should be kept under 200. But the irony of all of this is that if you're trying to keep total cholesterol low, you're assuming all components that make up the total should be kept to a minimum.
Most people know this is hardly the case. As I mentioned, having a lot of large, fluffy Pattern A LDL particles is not nearly as harmful as having a lot of Pattern B. Also, when it comes to HDL cholesterol, or the so-called "good" kind, every leading health authority suggests we need to keep this number as high as possible. This seems like a big contradiction to say keep some cholesterol particles, like HDL, high, while applying an arbitrary cap to total cholesterol.
Statins do a lot more harm than good. Though statins do lower LDL cholesterol (which I hope I've already convinced you is not necessarily a good thing), here are a few examples of the documented negative consequences of taking statins:
- This 2013 article found a 21% increased risk of death among women with breast cancer who took statins compared to those who didn't. Other studies have documented the link between statin use and musculoskeletal diseases and joint pain.
- Compared to people who did not use statins, statin users had had a 50% increased risk for any musculoskeletal pain, a 59% increased risk for lower back pain, and a 50% increased risk for lower extremity pain.
- This review article documents the ample evidence showing increased risk of cardiovascular disease in women among statin users, including a three-fold increase in risk of coronary artery and aortic artery calcification.
- Statin use has been shown to hinder the positive effects of exercise among overweight and obese individuals.
It's all about inflammation. If there is one thing to worry about instead of cholesterol, Moore
argues, we should be much more concerned about inflammation in the body
and the things that cause it. This is the true cause of atherosclerosis.
In his words, "without inflammation, cholesterol can't harm you." It's really all about cholesterol oxidation, which is nearly a two-fold better predictor of heart disease risk than simply looking at cholesterol alone. So,
we should be focusing more on things that cause chronic inflammation in
the body, which results from poor diet, smoking, lack of sleep,
infrequent exercise, elevated stress, and a compromised gut, just to
name a few that Moore references. One of the best blood markers for
determining the amount of chronic inflammation in the body is something
called high-sensitivity C-reactive protein, or hs-CRP. Many experts have
argued that hs-CRP is a much better biomarker to track because it's a
much better predictor of heart disease and health complications than
total cholesterol or LDL.
****
This book is definitely for everyone. I thoroughly enjoyed the balance struck between offering practical guidance while underpinning it all with sound science. If you're trying to cut through all the noise out there on cholesterol or you're interested in tracking your own health and wellness, this is definitely worth the read. My only critique - but this is coming from a researcher who loves evidence - is the lack of citations in the book. Moore does provide some suggested references for additional reading, but I personally could've really benefited from the book to a greater degree with citations, particularly for many of the chapters discussing the science.
Nonetheless, I highly recommend taking a look at this book. It'll definitely challenge (and maybe even change) the way you think about cholesterol.
Note: I was not compensated in anyway for writing this posting. Views are my own.
