I’d like to welcome Dr. ER (his alias when writing here) to my website as a contributing author. I have known him for a long time and he’s a brilliant guy that is very thorough and objective. I’ve brought him here because I respect his opinion, I know he stays current on research and he can offer some insight that us meatheads don’t quite have the education to be doling out advice on. He specializes in cardiology so he’s got a very strong base in this field.
While there are some very intelligent fitness/health coaches out there, sometimes we go beyond our scope. We know what we know and we should try to stick to it. If you have a following you need to be a bit more careful in what you write about and give “advice” on. For example, I’ve seen some fitness coaches cover things like vaccines which I know they have zero background to safely handle such an important topic. While the world of medicine and health should blend in some facets there are some topics we should tread carefully into.
This will likely be a 2 or 3 part series as I’d really like to provide people with a chance to understand the truth behind cholesterol, heart disease, statins, and so on. I will let him handle the heavy lifting and tough medical stuff, then I will share some of the dietary methods I have used to help clients lower and control cholesterol levels.
1.) Cholesterol is often a topic we see some fitness writers discuss. I personally believe cholesterol is grossly misunderstood by the vast majority of people. There also seems to be a fair amount of contradictions and myths that contribute to the confusion. Can you give us a brief primer on what cholesterol is and the important role(s) it plays in the body?
Dr. ER: Cholesterol is a lipid (fat) molecule that plays many important roles in our bodies. Unfortunately, most of these roles honestly have little relevance to anyone other than the scientists who study cholesterol. For the rest of us, it’s important to know that cholesterol serves as a vital component in our cell membranes and keeps these membranes fluid and adaptable. Additionally, the basic cholesterol molecule can be modified in our bodies, usually in the adrenal glands and gonads to form the various steroid hormones, like aldosterone, cortisol and testosterone. Lastly, cholesterol is modified in the liver to form bile salts that help us to absorb the fat soluble vitamins (A,D, E and K) from our diet.
2) A lot of people will get their annual blood work and be told they need to lower their LDL or “Bad cholesterol” levels. Why are high LDL cholesterol levels so bad?
Dr. ER: In studies, doctors have found that high cholesterol levels, specifically LDL cholesterol, are associated with atherosclerosis. Atherosclerosis is a disease of the blood vessels, which results in the buildup of cholesterol within the vessel walls. Most of the time, this isn’t a big deal, since it was discovered that every single person who is older than the age of 12 has atherosclerosis. The well known complication of atherosclerosis is the myocardial infarction (heart attack) and cerebrovascular accident (stroke), however, atherosclerosis is a disease that can affect any blood vessel in your body, and as it progresses, cause severe complications.
3) Do you believe that high LDL cholesterol levels cause atherosclerosis?
Dr. ER: In order to understand why doctors want you to have lower LDL cholesterol levels, you have to look at the history of how cholesterol became one of the villains of modern medicine. Atherosclerotic heart disease has been around since humans evolved (Even ancient Egyptian mummies were found to have it when they were scanned). It’s hardly something new that came with the rising popularity of Mickey D’s (although interestingly, the Japanese had much lower rates of atherosclerotic complications until their diet became more westernized). After World War II, a group of researchers joined together and started The Framingham Heart Study. They took thousands of people living in the suburban town of Framingham, Massachusetts and observed them over many years. The basic concept is that they then went back and looked at the people who developed atherosclerotic heart disease and tried to find common links between these people. They found links between heart disease and many things, including smoking, high blood pressure and yes- LDL cholesterol. This certainly wasn’t proof that LDL caused atherosclerosis, but it was enough to spur researchers on to try to lower patient’s LDL levels with medications. Many drugs were developed, all acting in different ways to lower people’s cholesterol. The main drugs used because they were the best tolerated and most effective were the statin medications (like atorvastatin and simvastatin).
As we studied patients over time on LDL lowering therapies, we noticed that they lived longer with less cardiovascular events (like heart attacks and strokes) than those who weren’t taking them. Millions of dollars were spent studying patients in order to determine what somebody’s LDL cholesterol should be in order to minimize their chances of complications from atherosclerosis. These guidelines are called the ATP-3 guidelines, and are what are used by doctors today to assess what a patient’s LDL cholesterol should be based on their risk factors, and what therapies we should use to get a patient to that level.
4.) Why is the LDL causing atherosclerosis theory so controversial now among doctors?
Dr. ER: In 2008, a study called the ENHANCE trial came out. They looked at patients who had persistently high LDL levels despite being on simvastatin, and split them into 2 groups. Half of the patients stayed on just simvastatin and the other half had a newer drug that lowered LDL even more called ezetimibe added to simvastatin. On paper the combination therapy looked great, since it lowered LDL levels even further. However, when they looked at the progression of atherosclerosis in the carotid arteries, they noticed that there was no difference between the 2 groups. What some doctors took from this study is that LDL may not be the culprit in atherosclerosis, and may just be a bystander and that atherosclerosis is really a disease of arterial inflammation. Others still believe the more traditional view that atherosclerosis is a disease of too much cholesterol in the blood stream depositing in the walls of the vessels.
Honestly, both theories don’t quite explain the entire picture, and both theories have evidence supporting them. Supporting the inflammatory theory, we see that in people with diseases of systemic inflammation (like lupus, psoriasis, rheumatoid arthritis, HIV, etc.) there is a much faster progression of atherosclerosis and its related problems. Supporting the theory that atherosclerosis is a problem of too much LDL cholesterol in the blood, we see that in patients with genetic diseases that prevent them from metabolizing LDL cholesterol appropriately and clearing it from their arteries (familial hypercholesterolemia syndrome patients), there is also an increased progression of atherosclerosis and its secondary results. Personally, I believe that like most things in science, atherosclerosis is far too complex to be explained by one of these mechanisms alone (or we would have been able to figure it out by now), and that both cholesterol and chronic inflammation are major players in explaining who has atherosclerosis and who has their disease progress to things like heart attacks and strokes. Regardless, statins appear to treat atherosclerosis effectively, regardless of what etiology is causing it.
5.) I know you and I have discussed the use of statins in the past and we have had our disagreements on them. Lipitor is currently the #1 prescribed drug in the country yet statistics will still point to increasing rates of Heart Disease, why is this? Is it a flawed statistic or does it have some merit? Also, do you think that statins are over-prescribed?
This is a lot of questions in one so I’ll try to break them down. Heart disease includes electrical conduction abnormalities, high blood pressure, valvular abnormalities, congenital heart disease, heart failure, and atherosclerotic heart disease. If you look at Americans, 1 in 3 people has heart disease by this definition. Statins (like Lipitor) only treat atherosclerosis, and are not used for treating (or have any effect on) any of the other types of heart disease, so it’s not really fair to blame statins for being ineffective at treating all types of heart disease. While Lipitor and other statins don’t clean out atherosclerotic plaques that have developed, the statins are good at keeping them from progressing and at stabilizing these plaques, keeping them from causing their dreaded complications.
When you say that the rate of heart disease is rising, at this point in time I honestly think it’s inevitable, mainly because it’s a bad statistic to analyze. One obvious cause for having more Americans living with heart disease is that these people are now living longer than in the past. When people had a heart attack before the 1980’s, there wasn’t much we could do other than just watch them, support them as best we could and hope that they didn’t die. Now most of the time in people having heart attacks, we can pop a stent in or give them clot busting medications, watch them for a couple days and then send them out to live the rest of their lives. These people have heart disease, and are going on and living decades longer, when in the past, they would have died in a couple of weeks. Also, on that note, in general we have people living much longer now than we used to, and unfortunately as we get older, things are almost always bound to not work as well in our bodies. Studies show that regardless of what animals do, as they get older, their blood pressure goes and atherosclerotic plaques develop. The number one risk factor for having a heart attack isn’t high cholesterol or smoking, it’s age. This is why I take issue when people cite the statistic that “heart disease is rising” in order to show that the statins are ineffective.
As far as statins being overprescribed, I disagree. People like to think that doctors get kick backs from the drug companies and that’s why they prescribe these medications to everybody. Trust me, I wish this was the case. I would have a much easier time paying my rent and utilities if drug companies paid me to prescribe their medications. In reality, we prescribe statins so much because they work. We’ve studied enough patients to see who will benefit from statins, and have developed guidelines to figure out what an individual should have their cholesterol at to be healthy. After watching what happens in millions of people, we know that if you are able to follow these guidelines, you live longer and your chances of cardiovascular complications decreases.
The chart above shows the guidelines for how to treat high cholesterol that I was talking about. Therapeutic lifestyle changes means not smoking, dieting, exercising right, etc… This should be done initially if cholesterol levels are reasonably low enough to expect enough improvement that the person will be able to reach their goal without medications. So you can see that your views are actually in line with most physicians’ views.
In the next installment of this interview we will discuss the side effects of statins, the doctors advice in managing cholesterol and some ideas on the dietary influences that surround cholesterol.