Cholesterol Clarity or More Disparity

From ‘doc’s opinion’, some more clarity on the industry debacle.

For decades cholesterol has been a major player when it comes to preventing heart disease. Measuring blood cholesterol and knowing your numbers is of key importance. If your numbers spell danger, you need to know what to do, otherwise you may be in big trouble.

In their book published last year, Heart 411: The Only Guide to Heart Health You´ll Ever Need, Marc Gillinov MD and Steve Nissen MD write: “High cholesterol has no symptoms; every day, we see patients who learn about their high cholesterol only after they arrive in the coronary care unit with a heart attack. Avoid this scenario. Have your cholesterol tested. If the results suggest you are at risk, review the information in the next few pages. It might just save your life”

Gillinov, a heart surgeon, and Nissen, a cardiologist, are both highly respected doctors and scientists at the Cleveland Clinic in Ohio. Both of them have delivered hundreds of invited lectures at hospitals, academic meetings and seminars in the United States and many other countries. I highly recommend their book for those who want to increase their understanding on how to prevent heart disease. Of course the book deals with many other issues than cholesterol.

In their book Gillinov and Nissen briefly go through the role of cholesterol in our body. They point out that “every cell in your body contains cholesterol, and you can´t live without it”. They highlight the importance of cholesterol for our cell membranes and the role it plays as a building block for many important hormones. They describe the “two types of blood-borne cholesterol, which are distinguished by their attached lipoproteins: low density lipoproteins (LDL) and high density lipoproteins (HDL)”. They point out that “high levels of LDL or “bad” cholesterol are associated with development of plaques in the arteries. Oxidation of LDL cholesterol in the blood enables it to enter the walls of arteries, leading to build-up of plaques. HDL or “good” cholesterol works in opposite fashion, removing cholesterol from the arteries and returning it to the liver, where it is removed from the body”

Gillinov and Nissen also tell us that “Eighty percent of the body´s cholesterol is made by the liver. While most people think that diet is the most important factor in determining cholesterol levels, this is a myth. Only 20 percent of your cholesterol levels comes from your diet, which explains why it is so difficult to reduce blood cholesterol levels via dietary interventions alone”. They say: “Understanding the limitations of dietary interventions often helps people accept the fact that they need to take cholesterol lowering drugs”. However, they underscore the importance of a good diet to influence blood cholesterol. In their opinion a good diet is “low in saturated fats, high in fiber and whole grains”.

They underscore the important role of LDL cholesterol in predicting the risk of heart disease: “Study after study has confirmed the strong relationship between high levels of LDL and heart disease”. Because HDL cholesterol appears protective, they believe that total cholesterol has major limitations as a predictor of heart disease. “The LDL level is the best predictor of the risk of heart attack and stroke, and the basic concept is simple: the lower the better.

The message from the experts is clear and simple: Know your numbers. LDL cholesterol is the most important subtype when it comes the risk of heart disease. Lowering cholesterol by diet is often not effective, but eating diets low in saturated fats and high in fiber and whole grains may be helpful. If you don´t succeed in lowering your LDL cholesterol, don´t be afraid to take drugs.

Cholesterol clarity – Jimmy´s Army

Jimmy Moore, author of the book Cholesterol Clarity – What the HDL is wrong with my numbers?

Jimmy Moore doesn´t believe the experts. I just finished reading his recently published book Cholesterol Clarity – What the HDL is wrong with my numbers? Moore´s co-author is Eric Westman MD, an internist in Durham, North Carolina.

Jimmy Moore is well known in the United States for his iTunes podcasts and his popular blog, Livin´La Vida Low-Carb. He has effectively dealt with obesity himself, and for years his cholesterol numbers have been really bad. He is motivated by his own experience and eager to help other people who are struggling to improve their health.

In the Introduction to his book Moore says: The title of this book is Cholesterol Clarity for a reason: The intention is to make the truth about cholesterol absolutely clear. This book is not for medical geeks. It´s not filled with complex terminology and jargon that makes the layperson´s eyes glaze over. ”

Although I´m probably a medical geek according to Moore´s definition, I must say I really enjoyed reading his book. More importantly, I also learned a lot from it. It is so well written and it has this extreme freshness about it. I never expected that I would agree with everything Moore writes in his book and I don´t. Of course that doesn´t mean I´m right and his wrong. However I like the way he approaches the subject and I admire his talent when it comes to explaining complex and highly debated issues.

Moore says: “I have no doubt that this book will be controversial. It challenges conventional wisdom about how we eat and live – rules that we have grown up with and followed for most of our lives”.

I agree with Jimmy Moore. I´m afraid many of my colleagues won´t like his book. They may even believe it to be dangerous because it contradicts many of the current recommendations from medical experts and public health authorities. However, I believe that everyone who is trying to take control off his/her own health will learn a lot from reading Moore´s book.

Jimmy Moore has no formal medical or nutritional health education. He does not refer to many scientific studies in his book. Instead, he has chosen to select an army of what he calls “trusted advisers who know the answers to the most pressing questions about health”. Moore constantly quotes these individuals throughout his book.

Moore´s army consists of twenty-nine individuals. Some are nutritionists, some are physicians, and some are neither. Some are respected scientists and leaders in their field. He has chosen many trustworthy and knowledgeable individuals, although obviously some may appear more trustworthy than others. Obviously Moore has handpicked a team of specialists who support his own theories. But I have to assume that all these individuals don´t agree with Jimmy Moore on everything he writes, but I could be wrong. What Moore fails to do is to also choose experts who don´support his opinion. I assume doctors Gillinov and Nissen would not have been fit enough for his army.

What´s the clarity all about?

After introducing his army, Moore goes on to describe the important role cholesterol plays in our body and he describes how little effect the cholesterol in our diet seems to have on blood levels of cholesterol. He discusses the evidence, or rather the lack of evidence linking saturated fat with heart disease. He touches on the evidence behind the lipid hypothesis, the fear of dietary fats, and the rising incidence of obesity and type 2 diabetes, which has occurred despite Americans dutifully cutting their fat intake. He criticizes the overwhelming emphasis on dietary fat and cholesterol consumption as the true culprits in heart disease. “Emerging evidence proves that these supposed health experts have been dead wrong and yet they continue to cling to this outdated and outright harmful information”. I assume Gillinov and Nissen belong to this group of “supposed health experts”.

Quite predictably, Moore discusses the role of inflammation in heart disease. Most specialists who doubt that cholesterol plays a direct causative role in atherosclerosis believe that inflammation is a key factor. However, although research indicates that inflammation plays a huge role, it doesn´t imply that cholesterol doesn´t matter. Indeed, atherosclerosis and heart disease may be caused by a complex interplay between different components of lipoproteins, including cholesterol, as well as oxidation, inflammation and other known or unknown mechanisms. Cholesterol and inflammation are not mutually exclusive.

Moore writes: “Without inflammation, cholesterol can´t harm you”, and he´s probably right. But he might as well have written: “Without cholesterol, arterial inflammation as we know it won´t harm you”.

Moore recapitulates what major health groups have said about cholesterol through the years. He manages very well to reflect the stringent, monotone, and scientifically unsupported view repeated for so many years, that the only thing that matters when it comes to diet and heart disease is too much cholesterol in the blood, and the importance of avoiding saturated fat and cholesterol in our diet. I´m afraid this approach has produced more harm than good when it comes to public health.

Moore criticizes the widespread use of cholesterol lowering drugs (statins). He believes there are alternatives to dug treatment when it comes to improving our health and “that lifestyle should be the first step to improving health and cholesterol numbers. He cites Dr. Thomas Dayspring when saying:”The real problem with most people is that they just don´t do what´s required to see improvements happen. If you want to go totally drug free, then you have to get serious about lifestyle and diet changes”. Obviously, many people could learn a lot from Jimmy Moore when it comes to improving health with serious lifestyle changes.

Moore attempts to redefine what we normally see as a heart healthy diet. This is not easy to do because the cholesterol issue has become such a big part of conventional thinking. An example of that is fearing that a highly nutritious food such as eggs is dangerous for your health because it´s rich in cholesterol. In Jimmy Moore´s mind Heart healthy does not imply eating less fat and more carbohydrates”. He is very skeptical about sugar, grains and starchy carbohydrates as well as omega-6-rich vegetable oils.

Moore discusses the question why “so many doctors are clueless about cholesterol”. He is “troubled by how little most traditionally trained medical doctors are taught about the nutritional component of health”. Sadly, I think he has a point here. The influence of nutrition and lifestyle on health definitively played a minor role in my medical training. This is an area where doctors have to improve. However Jimmy Moore could be overestimating his own and is army’s greatness when saying: “Apart from the experts quoted in this book, the mainstream medical community seems determined to stick with outdated and potentially dangerous ideas.”

Moore does a very good job in explaining the meaning of different laboratory numbers, total cholesterol, LDL cholesterol, triglycerides, as well as the role of newer tests like ApoB, LDL-P, Lipoprotein (a), particle size assessments (patterns A and B) and C-reactive Protein (CRP).

Cholesterol clarity or more disparity

It´s quite interesting to compare the approach by Gillinov/Nissen and Moore/Westman to the role of cholesterol in heart disease and cardiovascular prevention. Gillinov and Nissen consider a heart healthy diet to be low in saturated fats, high in fiber and whole grains. Jimmy Moore and his army on the other hand believe that eating less carbohydrates and more fat is beneficial.

Gillinov and Nissen consider it positive that 25-30 million Americans are taking statin drugs to lower the risk of heart disease and stroke. Jimmy Moore and a part of his army however see statin drugs as a marketed poison. How can we explain such a huge difference of opinion? Who´s right and who´s wrong?

I think Jimmy Moore handles the question elegantly in the beginning of his book when he writes: “For years, popular wisdom has held that having elevated levels of cholesterol in your blood is extremely dangerous, leading to heart attack, stroke, even death. Therefore, it must be lowered by any means necessary. Those means include cutting saturated fat and cholesterol from your diet and taking cholesterol lowering prescription drugs. Sound familiar? Well, some of us took the time to stop and ask a few simple questions: Isn´t the human body a lot more complex than this simplistic solution implies? Isn´t our health dependent on more than one single marker like total cholesterol?” I suspect Gillinov and Nissen agree with these words. So maybe there is no disagreement after all.

Although I don´t believe Jimmy Moore has managed to resolve all the fog around the cholesterol issue he certainly has given it an honest and fresh try. I know I will read many chapters of his book again and again. Although I may not necessarily always find the truth, I know for sure I will enjoy it, and I´m quite sure it will help me become a better doctor.