Less statins, not more

Earlier this week I wrote about Jimmy Moore's new book Cholesterol Clarity, which really dives into many of the misconceptions around the issue and tries to cut through the noise, so to speak.

You can read the full post here.

One of the main take-aways for me from that book was around the prescription and use of statin drugs, particularly how much of a "well oiled machine" this system has become. Most importantly, there are a variety of documented side effects and negative impacts on long-term health, which often get swept under the rug because they do one thing (which doctor's have been taught is really the only important thing about cholesterol) really well - lower LDL cholesterol.

As it turns out, however, we're likely to see the prescription of statin medication dramatically INCREASE in the coming years. Here's why.

On Tuesday of this week, the American Heart Association and the American College of Cardiology released new guidelines on obesity, cholesterol, risk assessment and lifestyle. In addition to stating that obesity "should be managed and treated like a disease" (that's the topic for an entirely different posting, and one that's stirred up quite a bit of controversy) the guidelines also suggest that "more Americans could benefit from statins."

Here are the groups who they recommend should take statin drugs:

• People without cardiovascular disease who are 40 to 75 years old and have a 7.5 percent or higher risk for heart attack or stroke within 10 years.
• People with a history of heart attack, stroke, stable or unstable angina, peripheral artery disease, transient ischemic attack, or coronary or other arterial revascularization.
• People 21 and older who have a very high level of bad cholesterol (190 mg/dL or higher).
• People with Type 1 or Type 2 diabetes who are 40 to 75 years old.

 So, if you find yourself in one of these categories and weren't taking a statin drug previously (and this (and this particularly applies to women where there is a great deal of evidence showing the significant drawbacks of taking statins), chances are your likely to hear the recommendation from your doctor the next time a cholesterol test shows high LDL-c levels.

I think a recent New York Times opinion article by Harvard Medical School lecturer John D. Abramson sums it up quite nicely:

"We believe that the new guidelines are not adequately supported by objective data, and that statins should not be recommended for this vastly expanded class of healthy Americans. Instead of converting millions of people into statin customers, we should be focusing on the real factors that undeniably reduce the risk of heart disease: healthy diets, exercise and avoiding smoking. Patients should be skeptical about the guidelines, and have a meaningful dialogue with their doctors about statins, including what the evidence does and does not show, before deciding what is best for them."

What's wrong with the conventional wisdom on cholesterol and how it could actually be harming us

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.

Tools to Track (and Hack) Your Own Health

One of the most exciting trends over the past few years has been the proliferation of tools to track your own health. No longer is your health a conversation reserved for a doctor's office, but there are more and more opportunities for people interested in their own health to track various aspects of it.

Whether the number of steps taken in a day, sleep duration and quality, heart rate variability (a measure of stress, which is being used more and more - this is a good podcast done by Ben Greenfield if you'd like to learn more), or even keeping track of individual lab results that measure a whole host of biomarkers, technology has allowed for more data. This has allowed for a unique niche of health and wellness experts, called biohackers, to spring up, but it's also allowed for something the online lab and personalized wellness company, WellnessFx, likes to call the "democratization of health."

I've become a huge fan of this individualized approach to health, including from a nutrition perspective. Our body's are unique ecosystems and what works for one person might not work for another. That's where this concept of individualized wellness comes in. I'm sure you've heard the saying that "you're the best expect of your own body," (or something like that) but I think there is a lot of validity to that statement. And technology has made it possible for an even deeper, more intimate expertise of our own physiology, genetics and health.

Over the past year or so I have been experimenting with a variety of apps to track different aspects of my own health. Here are a few of my favorites.

Sleep Time - Made by Azumio, which also makes a variety of other health and wellness apps (including the next one on my list), this particular app allows you to track the duration and quality of your sleep through your smartphone (I've only used the iPhone). The app uses sensors within your smartphone that can detect movement, and tells you the time you spend in deep sleep and light sleep. I found the app was pretty accurate, but practically was sometimes difficult to use. For example, you need to sleep with your phone fairly close to your pillow so it can most accurately sense movement. There can also be a counter-productive mental game that you play with yourself, wanting to score well on your sleep score, but by over thinking it, I found it even harder to fall asleep. 
 
Argus - Another app by Azumio (no they don't pay me), Argus is a so-called lifestyle app that functions as a pedometer, calorie counter, and keeps track of your meals and daily water intake. I'm a big fan of the reminders Argus has when you've been sitting for too long. Getting caught up in our work is a frequent occurence, and I'm no exception, and these are helpful reminders to make sure we all step away for a few minutes and go for a walk. My favorite part of the app, though, was that you could take pictures of your meals, which are stored directly in the app. Also, because it's an Azumio app, Argus conveniently syncs with other Azumio apps, such as Sleep Time or Instant Heart Rate, to create a useful dashboard of data.

Food Sense -Not by Azumio, this is an app by the Bulletproof Exec, Dave Asprey, and one I've actually been using the most recently. I haven't quite tapped into it's full capabilities, which also include measuring heart rate variability, but one of its main functions is to detect food sensitivities through a series of heart rate measurements around meal times. It also includes a handy relax function, which takes you through deep breathing exercises, which can be used by itself, or in conjunction with the heart rate variability function. I also like that the app is compatible with a number of wireless heart rate monitor straps, which can be used to measure heart rate, or it also has options of measuring it through the camera lens of your smartphone.

So, give these a try and let me know your thoughts. Also, post your favorite health and wellness apps in the comments. I'm always looking for new ones to try.

What do other countries think is American food?

My wife and I spent the past week on vacation in Europe, splitting our time between Paris and Rome. One of the most fascinating parts about the trip came on our third day in Paris, and I had to share.

The French are, of course, known for their delectable food: freshly-baked croissants and bread, cheese, and meats. So, we thought it would be interesting to check out a well-known grocery store in Paris. We strolled past the bakery with all the deliscious breads, macaroons, and pastries on display. We checked out the meat counter, the wine, and the cheese.

But, we also took a quick look at some of the international sections of the store, including one shelf of "USA" food. In this case, this picture says a 1,000 words.

It's almost embarrassing to think that this is the kind of food that other countries really think of when they think of American food -- processed junk! Shelves filled with mac 'n' cheese, salad dressings (in Italy they serve extra virgin olive oil and vinegar - that's it!), canned soups, beef jerky, roasted nuts, and all sorts of condiments, many with sugar as the first or second ingredient.

Is this the food culture we want to be perceived as having in the United States? I sure don't!

Then again, the items weren't too far off from what fills the shelves of many convenience stores across the country.

How savage are you? Race report from the Savage Man 70.0

It’s billed as one of the toughest triathlons in the country.

Savage Man 70.0 Triathlon.

Pros and amateurs alike come to Deep Creak, Maryland to test whether they can scale the infamous 30%-grade Westernnport Wall (go to the website, watch the YouTube video, and you'll see rider after rider falling over). Savage Man boasts more vertical feet (almost 7,000) of climbing on its bike course than almost any other half-Ironman distance race around. Oh, and the run course is no walk in the park either (well, actually, the savage bike does reduce many to periods of walking).

This race has been on my to-do list ever since I broke into the sport of triathlon. Though my attempt at the full distance will need to wait, myself and two buddies entered the relay – but, not just for the amazing experience, we wanted to win. My friend, Jake, who is currently training for Ironman Florida did the swim. My sometimes-riding companion and uber cyclist, Kurt, took on the bike leg. And it was up to me to close things out on the half-marathon distance run.

****

I started off the weekend with a big mistake. My wife and I drove out Saturday (race was on Sunday) so we really only had that afternoon to really enjoy the atmosphere at there. After the almost three hour drive from DC to Deep Creak, we went straight to packet pick-up, and then checked into our hotel. For the remainder of the afternoon we sat out back and enjoyed the peacefulness of the lake. Man I wish we came out here a few days earlier.

One of biggest challenges the day before a race - and this one was no different - is finding ways (sometimes creatively) to take in some quality food. During training it's easy to take the nutrition component of race (or big workout) preparation for granted. I can make my omelet and salad on Saturday for lunch, followed by some veggies and fish for dinner (maybe with a small sweet potato thrown in or a small serving of rice if it's going to be a long/tough workout on Sunday). 

But on the road it's an entirely different ballgame. There's certainly some opportunity to prepare by packing some of the staples that travel easily (things like coconut oil, coconut manna or flakes, nuts, avocado, and maybe some chopped up veggies if the drive isn't too long), but for main meals you need to rely on the restaurants and grocery stores around the race site. As beautiful as Deep Creak, MD is, I wouldn't necessarily call the dining options extensive. But, I made do and was a bit creative as well - you have to be.

So, the day before the race my nutrition looked something like this (a far cry from the traditional carbo-loading approach that seems to be common practice in endurance sports):

Breakfast at home: 3 egg omelet with kale, avocado, and bulletproof coffee (black coffee mixed with coconut oil and grass-fed butter)
Snack on the road: Handful of cashews
Lunch at about 3:30pm at the hotel: Crab soup and salad topped with shrimp
Dinner in Deep Creak: Bowl of hummus, pulled pork on a house salad (I mostly just ate the pork), and tomato/mozzarella on top of a bed of spinach.
Dessert: A few spoonfuls of coconut manna

****

One of the best parts about race morning...the race started at 8:30am! No need to worry about waking up at some ridiculous hour before the sun comes up.

There was definitely a chill in the air. The low temperature the night before was down in the high 40's/low 50's. At the same time, waking up and walking outside to the cool, crisp, fresh air felt incredible. It was definitely going to be a BEAUTIFUL day to race - lots of sun and warming up to the 70's.

Since I was the third leg of the relay, I had to do a little planning with my nutrition that morning. I figured I'd probably start the run leg close to noon, so I made sure to have my breakfast portable enough that I could take it with me to the race site. Breakfast was pretty simple: a few spoonfuls of plain white rice; a banana; an avocado; a handful of cashews; and a coffee mixed with coconut oil.

****

After picking up our team's timing chip, and addressing an issue of missing bike numbers (which we never got at packet pickup so had to track them down on race morning), the swim was finally about to go off. Jake had a pretty solid swim at 34 minutes, though he's probably say it was sub-par. Kurt and I waited in transition.

Once he came running through to Kurt's bike rack position, I would take the timing chip off Jake's ankle and put it on Kurt's - hopefully without fumbling. Only two relay teams came through before Jake did. We were looking pretty good. Jake finally came around the corner, totally out of breath from running up the steep hill (and steps) leading from the lake to the transition area.  

I had my 15 seconds of fame, changing the timing chip from Jake's ankle to Kurt's, and then it was back to the waiting game for me. Kurt, in the meantime, headed off for his 56 miles and the infamous Westinport Wall. I'm sure he was nervous, but I was pretty confident he could ride a solid 3 hours. The guy can definitely ride (I did a century ride with him last year in hilly northern Virginia and he rode a single speed....A SINGLE SPEED). I wasn't worried.

But I was sure impatient. Did I mention that the worst part about the race was the waiting?

About an hour before the estimated time I thought Kurt would arrive in T2, I went for a nice warm up. I pretty much stick to the same basic warm up that's worked for me over the years. Why change things if it works?

I went into transition and waited. Took a few minutes to gather my thoughts and visualize what I wanted to do. The course is pretty darn tough with a lot of hills. There are basically four big climbs of about 100-150 feet, not to mention the rolling hills in between. I thought somewhere around 1:25-1:27 would be pretty darn good. (As an aside, the course record is 1:18, which is unbelievable considering the course). 

The first relay group came into transition. I checked my watch. What seemed like 5 or 7 minutes later, another group came through. Now I was starting to worry a little bit. There weren't too many athletes who had come through T2 at this point, so I knew Kurt couldn't be too far behind. 

All of a sudden, I saw him coming down the hill. I met him at the end of transition, took the timing chip off his ankle, and I was off. My job now...run down the two relay athletes ahead of me. I didn't know exactly how far ahead they were, but it definitely seemed like I had a fair bit of ground to make up.

The run course is mostly on pavement, but there are some portions on trails (which I actually liked because of the change in running surface). The other advantageous aspect of the course was that it was a double loop, which also included a few out-and-back components. This basically allows you to see other athletes who are ahead of you and gauge exactly how far ahead.

I came up to the first mile marker and checked my watched to see what my pace was. In the excitement of sprinting out of T2 I forgot to start my watch. Come on! It felt like a solid first mile, maybe 6:30 pace or so. I started my watch right at the first mile marker so I would at least have my time for the remaining 12.1 miles. But, time didn't really matter at this point. My only goal was to track down those two other relay teams that were ahead of me. 

One big way I tried to make up time was by attacking on the downhills. With a fairly hill course, it's easy to use the downhills as a recovery period after the climbing portion. You crest the hill, your heart rate is through the roof, and you rely on gravity to do the work for you. Instead, I tried to use the downhills to my advantage. Shorten the stride, increase the cadence and go for it. 

The first lap of the double loop run course I was essentially flying blind. I didn't have a great sense of how far ahead the two lead relay runners were. My focus was on pushing the flats (the few that there were), steady on the hills, and then attack on the downhills. I've always been a fairly descent runner on hills, so I tried to use that to my advantage.

Probably THE best part about Savage Man is just the level of enthusiasm by spectators, whether they are family and friends of athletes, or just the locals. They certainly had a knack for finding the best spots along the course as well - the spots when you really need some encouragement. Going up the first major hill on the run course I passed some spectator with a giant blow-up shark who was running alongside an athlete. Why a shark? I have no idea. But the level of excitement was incredible. It was easy to tap into that energy and feed off of it.

I was coming up to the end of the first loop. A quick check of the watch and guessed I was around 45 minutes or so. Around the corner, up a small hill, and I headed toward the start of lap 2. My two teammates, Kurt and Jake, their significant others, and my wife all cheered me on as I passed.

"What's the split?" I yelled to the group. Jake, knowing what the heck I was talking about, yelled back, "about a minute and a half." This was the time I needed to make up to catch the leader.

Alright, time to get to work. I knew I had made up some ground on the first lap, I just couldn't tell if I'd run out of miles to catch the runners ahead of me. Coming up at the first turnaround, I spotted the other two runners coming towards me. I could gauge a little bit. I knew I was slowly making up ground. 

Not too long after that I passed one of the relay runners to move into second place. That boosted my spirits. I wasn't too far behind. I attacked the upcoming hill. After the half-mile climb I kept up the pace and really attacked the downhill. 

My eyes stayed fixed ahead of me, trying to spot the relay leader. At about mile 10.5 I finally had the leader in my sights. And lucky for me, we were just coming up on the last major hill of the course, an off-road trail called Fire Tower Trail, which has a solid grade in the teens. The leader seemed to slow a bit when we hit the incline. I knew I had to push on this hill. I went for it. Gave it everything.

I moved into first place just as we rounded the turnaround at the top of the hill. I grab a sip of Coke from the aid station at the top and went after the downhill. I wanted to increase the gap. 

I didn't look back after that. I knew I had it. Coming up to the finish line was an incredible (after all, that is the drug for us endurance athletes, isn't it?). I saw my wife in the distance standing next to the finish chute. My teammates jumped up from sitting on the ground to cheer me across the line. I was filled with a sense of accomplishment, not just for how we did as a team, but because I felt I had a really strong race.

Our team - 'The Other Team' - took first overall in the relays, and our combined time was 14th fastest overall. And for my run leg, I had the 3rd fastest time at 1 hour 28 minutes. 

Oh, and did I mention we'll be back next year to defend our title?