Dana Carpender: Jimmy, Dr. Westman, thanks so much for talking with me! Let’s start with a question for Jimmy. You have a lot of doctors and other people with serious credentials weighing in on this issue in the book. What were the greatest issues of unanimity? On what issues did you find a broader spread of opinion?Jimmy Moore: I invited twenty-nine of the world’s foremost authorities from a variety of health-related fields to weigh in on the subject of cholesterol. Almost universally, they agreed that the obsession with LDL-C and total cholesterol as the only markers that matter on your cholesterol test results is incredibly shortsighted. Many of my experts are no fans of measuring cholesterol while others prefer to use the more advanced cholesterol tests that measure for the LDL particles, particle size and other signs of metabolic disturbances, including measuring for actual diseased state such as looking for markers of inflammation and signs of calcified plaque in the arteries. And yet the official cholesterol guidelines are STILL predicated almost exclusively on those two numbers I mentioned earlier—LDL-C and total cholesterol. It’s amazing with all the technological advances we’re stuck on decades-old thinking.
Dana: I’m guessing – hope this isn’t a spoiler – that you come down on the side of total cholesterol being a non-issue in heart disease etiology. What do you feel is the triggering event? Or events?
Jimmy: Total cholesterol is like knowing that the total score at the end of a baseball game is 25. You don’t know if it was a blowout score of 24-1 or a nail-biter at 13-12. While an elevated total cholesterol level might be an indication of other things that might be going on (and we share what some of things might be in the book), it doesn’t really tell you much in terms of your heart disease risks. The real enemy, and the thing we need to be most concerned about, is chronic inflammation brought on by the consumption of carbohydrates, mostly breads, pasta, sugar, and starchy foods, as well as vegetable/seed oils, elevated stress levels and a lack of quality nutrition in the form of omega-3 fats in your diet. You cannot have heart disease without inflammation—it’s just impossible! And yet the very substance that is trying to help your body deal with inflammation—cholesterol—is the thing that is blamed for heart disease. It’s like blaming the firefighters putting out the fire at your house for starting the fire. That’s just plain ridiculous!
Dana: I’ve seen various statements as to which blood lipid ratios are most important: TC/HDL, HDL/Triglycerides, etc. Is there one particular ratio you feel people should be paying particular attention to? And why?
Jimmy: While there is certainly some debate on this issue, the one that seems to rise to the top is the triglyceride/HDL ratio. I call these two markers on your standard cholesterol test the “forgotten and ignored” markers. And yet they hold such a valuable predictive value for your heart health risks if that ratio is 2.0 or less. Optimally you’d like to see a 1/1 ratio with your HDL being above 70 and your triglycerides below 70. Raising HDL can be done in a myriad of ways, including eating more dietary fats like butter, lard, coconut oil, full-fat meats and cheeses and other high-fat foods. As for triglycerides, they are intricately tied to your carbohydrate tolerance level and intake. Ergo, keeping your fat levels high and your carb consumption to your personal cutoff point will make this ratio sparkle. And yet how many doctors even talk to you about your HDL and triglycerides? Not nearly enough, because statin drugs don’t alter these numbers like they do LDL-C and total cholesterol. That’s the bottom line truth to all of this.
Dana: Similarly, what tests do you feel people are ignoring at their peril, and what kinds of results should be shooting for?
Jimmy: Aside from ignoring HDL and cholesterol, many people have no idea there are different kinds of LDL. What you want is the Pattern A—large, fluffy and buoyant—LDL as opposed to Pattern B—the small, dense and dangerous kind. Getting an NMR Lipoprofile test will tell you exactly how many LDL particles you have floating around in your blood as well as the size of those particles. There is debate over whether LDL particle count or size matters most and we present both sides of this issue in the book. But the sad reality is most people haven’t even heard of any of this before and are being prescribed statin medications based on a number that really doesn’t tell the whole story (total cholesterol) and a number that is actually calculated and not measured directly (LDL-C). Can someone please tell me why in the 21st Century we are stuck on decades-old thinking regarding cholesterol?
Dana: Jimmy, what sort of shift did you see in your numbers after you initially went low carb, and then how did the numbers shift during your NK experiment?
Jimmy: After my original Atkins low-carb success in 2004, my HDL went up to 72, my triglycerides went down to 43, my LDL-C went up to 185 and my total cholesterol was around 285. Of course, when my doctor saw the LDL-C and total cholesterol, he was trying to push a statin drug on me. I refused since I had already experienced the pain in my joints and muscles from taking both Lipitor and Crestor before I started low-carb living. It wasn’t until I started blogging and podcasting that I learned more about advanced cholesterol testing and measuring inflammation markers like hsCRP levels (which we talk about in the book) that I started measuring those too. All of those stellar markers I saw prior to beginning my nutritional ketosis experiment actually got even better—HDL rose, triglycerides dropped, CRP fell, and the number of small, dense LDL particles diminished as well. It was as if I took my low-carb lifestyle to a new level of healthiness that I had never seen before. These changes simply astound me!
Dana: Dr. Westman, what sort of shift do you generally see in people’s blood work numbers? How quickly? And what’s the most dramatic change you’ve seen?
Dr. Eric Westman: After changing to a low carbohydrate lifestyle, the first changes in the blood work that I see are a reduction in blood glucose, which happens on the first day, and a reduction in the blood triglycerides, which happens in the first few weeks. The rise in HDL (the good cholesterol) typically takes months to see big changes. The effects that I see from the diet alone are comparable to SEVERAL medications, or in some cases, the reduction in dietary carbohydrate is MORE powerful than any combination of medications.
For type 2 diabetics, I have tapered and eliminated 180 units of injected insulin per day in 3 days! For blood triglycerides, it is typical to see a reduction from 500 mg/dL to 150 mg/dL. If they did not have a triglyceride problem, many people will end up with triglycerides between 50 and 100 mg/dL. All of these changes are healthy ones.
Dana: Statins scare the ever-living heck out of me, and as I understand it they have not been shown to reduce the rate of heart attack in anyone but people who have already had a first heart attack. Dr. Westman, do you think use of statins is ever justified? If so, in whom?
Dr. Westman: While I’m not a huge fan of statins either, there is evidence that statins can reduce the risk of heart disease progression in people who already have heart disease, but this effect is rather small. Aggregated over the entire population the effect is large, but for a given individual there may not be any benefit at all. Fortunately, lifestyle changes like the low carbohydrate lifestyle can normalize the fasting lipid profile and take away the ‘need’ for a statin in most people.
Dana: Dr. Westman, in your professional opinion, is there one main cause of atherosclerosis, or is it less clear than that? If there is one main, driving cause, what do you feel it is?
Dr. Westman: Great question. Lots of confusion here because we talk about “the cause,” rather than “contributor,” and sometimes arguments occur because we are talking about a several step process–much like when people argue about gun control and disagree about whether guns or people ‘kill people’–or is it the bullet?
The final common pathway for all the ‘contributors’ appears to be inflammation. Inflammation sets up the process favoring cholesterol deposition in the arteries (atherosclerosis). The main contributors to atherosclerosis are tobacco smoking and diabetes, and rarely hereditary elevated blood cholesterol problem.
Dana: Also for Dr. Westman: You mention recommending your patients get their “arteries checked” from time to time. How is this done, how often should it be done, and how does one get one’s doctor to order whatever test it is?
Dr. Westman: In many health systems, a doctor cannot order a screening test for the arteries unless the individual has symptoms of an arterial disease, or is at high risk for arterial disease. In our area, there are companies that provide these tests, so you just have to see what is available in your area. Because these tests are ‘non-invasive’, or harmless, there is no need for a doctor’s order.
Dana: It is a little-known but important fact that low total cholesterol is actually associated with increased all-causes mortality. How low? Do you have any idea why this should be? And why does it seem most doctors don’t know this?
Jimmy: The obsession over the marketing of cholesterol drugs to “go lower” has led to the unintended consequence of people not having enough cholesterol in their bodies to heal the damage done by chronic inflammation. We share the story of the late “Meet The Press” anchor Tim Russert as a perfect example of someone who suffered the unfortunate fate of dying from his first heart attack because he had too low cholesterol levels. When he died, Russert’s total cholesterol was 105. By every conventional standard this was the picture of perfect health—and yet he died in his 50’s. Why? Because the protective role that cholesterol plays in the body to help heal the damage that is being done was stripped away by the statins and low-fat diet he was consuming. These are the dirty, behind-the-scenes realities of what is happening to the health of good, innocent people who are simply trying to do the right thing for their health. And isn’t it ironic that all of these “healthy” actions are actually the very thing that is making people become increasingly unhealthy?
Dana: Dr. Westman, what were you taught about heart disease etiology in medical school? When and how did you begin to question the cholesterol hypothesis?
Dr. Westman: I, like most other US physicians, was trained that cholesterol and saturated fat in the diet raised the blood cholesterol and saturated fat, and that was the cause of heart disease. I began to question this teaching when I learned in depth about evidence-based medicine– about hypothesis-generating vs. hypothesis-testing research–and learned that this ‘cholesterol hypothesis’ came from hypothesis-generating research.Dana: It’s becoming clear that LDL particle size – large-and-fluffy versus small-and-dense – is far more important than total LDL. Yet few doctors test for it yet. Any suggestions for how to talk a doctor into testing for LDL particle size?
Jimmy: Every lab and doctor’s office in the United States can run this test through LabCorp. I’ve heard from many of my readers who say their doctor refuses to run this test unless you have a family history of heart disease; they deem is completely unnecessary. But you are the boss; your doctor is merely a consultant in your health decisions. Ask for the test and they should run it for you. If all else fails, there are websites online that allow you to order health tests and get the blood drawn without the use of a doctor’s office. We list several of these in Cholesterol Clarity. There’s also a link to some low-carb-friendly physicians who won’t scold you for eating a low-carb, high-fat diet at my Low-Carb Doctors blog: http://lowcarbdoctors.blogspot.com
Dana: Bottom-line it for us: What’s the take-away message of this book?
Dr. Westman: Living a healthy lifestyle is more effective than taking a cholesterol-lowering medication. Be a careful consumer of health care advice.
Jimmy: If you obsess about LDL-C and total cholesterol as the only things that matter on your cholesterol panel, then hopefully Cholesterol Clarity will shift your thinking away from that, to realizing there are much more important things to be concerned about regarding the state of your heart health, and that the individuality that each of us has requires us to carefully consider the plan of action that is right for us. Taking a medication as the first line of defense rather than as a “when all else fails” option, is never the answer. Helping people understand this is the ultimate message and purpose of this book. And telling people “what the HDL is wrong” when their cholesterol numbers come back wacky.