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Which Is the Real Villain In Heart Disease – Cholesterol or Inflammation?

By Michael Jorrin, "Doc Gumshoe", January 16, 2020

The answer to that foolish question is certainly going to be “both.” But the finger pointing at the guilty party has wobbled around a good deal in the past few years, and just before Christmas, the American Heart Association came out with a set of dietary recommendations once again apparently putting at least some blame for heart disease on dietary cholesterol. This is a pretty big switch. In the past decade, the recommendations have bounced around a good bit; for example, as late as the 2018 cholesterol management guidelines from the American College of Cardiology and the American Heart Association shifted the emphasis on cholesterol management away from dietary cholesterol.

What, we may ask, is going on? Here’s how the American Heart Association science advisory puts it:

“Historically, nutrition guidelines for reducing cardiovascular disease (CVD) risk and achieving optimal plasma lipoprotein profiles have included recommendations to limit dietary cholesterol. However, contemporary guidelines for CVD risk reduction from the American Heart Association (AHA) and American College of Cardiology (ACC) and the “2015–2020 Dietary Guidelines for Americans” have not issued explicit guidance for dietary cholesterol. Because of the inconsistencies in the evidence base and the inherent difficulty in conducting and interpreting studies to isolate the independent effect of dietary cholesterol on CVD risk, controversy has ensued about whether dietary cholesterol should be a target for CVD prevention and management. (Carson et al “Dietary Cholesterol and Cardiovascular Risk” Circulation. 2019;140:00–00)

From where Doc Gumshoe sits, the AHA is being more than a bit weasely. To answer my previous question, what has been going on is that for several decades, the official positions of the major medical associations emphatically advised limiting the consumption of foods that were high in cholesterol, which specifically included red meat, eggs, and full-fat dairy products. But in the past five years or so, they have effectively backed away from those recommendations, without explaining why they did so. And then, in this past year, the AHA perhaps realized that they may have backed away a bit too far.

What do we know about cholesterol that got us to this point?

More than a century ago, it was determined firmly and clearly, and without “inconsistencies in the evidence base,” that cholesterol was the substance deposited in the walls of human arteries and was the main component in arterial plaque.

It was understood that cholesterol is a simple molecule, solid at body temperature, and not water soluble. It is present in virtually all our tissues, providing structure, and is absolutely essential for life. But, since cholesterol is not water soluble, in order to be transported in our bloodstream, it has to hitch a ride with substances that can be carried around in blood. These are lipoproteins – little particles containing both proteins and lipids, not in any fixed chemical combination, but bundles of varying sizes. Cholesterol attaches to the lipid part of these bundles, and the protein part permits them to be transported in blood.

These particles range in size and density. The low-density, loosely packed bundles, called low-density lipoprotein cholesterol, or LDL-cholesterol, are the ones nicknamed “bad” cholesterol, because they are the ones that are apt to shed the cholesterol molecules themselves, which can attach to the walls of the arteries and even penetrate those walls. But, we have to remember, the LDL-C is absolutely essential to our lives, because those particles are the ones that convey cholesterol to where it’s needed, which is pretty nearly everywhere in our bodies.

The smaller, denser bundles, called high-density lipoprotein cholesterol, or HDL-cholesterol, carries cholesterol back to the liver, where it is taken up by the bile and carried in the bile duct to the colon for excretion in the feces. Therefore, HDL-C is dubbed “good cholesterol.”

It’s worth just mentioning that only about 15% to 20% of the total cholesterol in our bodies enters our digestive systems as cholesterol. The rest we synthesize daily. Some of the foods we eat are more easily transformed into cholesterol, such as solid fats, especially partially hydrogenated fats (transfats). But no matter what we eat or don’t eat, we’ll go on synthesizing cholesterol, because we need it.

The balance between LDL-C and HDL-C is a homeostatic mechanism. Those two types of particles have properties beyond their role as cholesterol delivery systems. LDL-C appears to be highly susceptible to oxidative damage, and may also inhibit the synthesis of nitric oxide, which is thought to be one of the body’s natural mechanisms to combat atherosclerosis. And HDL-C has the opposite effect. Its principal lipoprotein, apo A-1, plays a part in preventing particles involved in atherosclerosis from adhering to arterial walls.

So, not only do LDL-C and HDL-C play different roles in cholesterol transport, they do the same with regard to arterial damage. We could say that the nicknames “bad” and “good” cholesterol are fully justified.

Maintaining good levels of HDL-C in the circulation is highly important to cardiac health. Some activities, such as exercise, have a beneficial effect on HDL-C levels. >It’s the view of many cardiologists that the ratio of total cholesterol to HDL-C is more indicative of overall cardiac risk than the total cholesterol value by itself, so, while a TC value of more than 200 is thought to be higher than the optimal range, this can be offset by an HDL-C value higher than 50.

However, despite the necessity of cholesterol in our bodies, for most of the 20th century it was taken for granted that cholesterol was the cause of atherosclerosis and a principal cause of heart attacks (myocardial infarctions, or MIs).

Efforts to reduce the risk of MIs by cutting back on foods rich in cholesterol failed to lead to reliably clinically effective results. In other words, people who significantly reduced their intake of eggs, butter, and beefsteak, did not have fewer MIs – at least, statistically.

It wasn’t until the mid-1990s that a drug, simvastatin, was clearly and definitively demonstrated both to lower cholesterol in the blood and to reduce the incidence of heart attacks. Initially, this beneficial effect was demonstrated only in individuals thought already to be at an elevated risk for heart attacks.

Statins target the formation of cholesterol, termed cholesterol biosynthesis, which takes place mostly in the liver. They inhibit an enzyme labeled HMG-CoA reductase, which is active in cholesterol biosynthesis. However, statins have no effect on cholesterol that enters our bodies as cholesterol – only on the process of cholesterol biosynthesis.

In the years since the results of the trial which demonstrated the effectiveness of simvastatin, several other statins have been developed, approved, and have become widely used. One, atorvastatin, trade named Lipitor, became the world’s all-time best-selling drug, racking up $125 billion in sales in the years before it became a generic.

If heart disease rates had remained at their peak in the years immediately before the widespread use of statins, there would have been about 10 million more deaths attributable to heart disease since then. However, heart disease is still the leading cause of death, both in the US and worldwide. According to the World Health Organization, more than 30% of all deaths on Planet Earth are due to some form of heart disease.

The large decline in the number of heart disease deaths in the US and other developed parts of the world can hardly be attributed to the use of statins alone. Other factors – improved options for the control of hypertension, a reduction in the numbers of tobacco smokers – certainly played a part, but the evidence for the role of statins in that decline is very strong.

Looking for answers to some puzzling questions

While acknowledging the role of elevated cholesterol in cardiac disease, there were still a number of questions to be answered. One of these was what caused MIs in individuals with supposedly “normal” cholesterol. A common factor, unearthed by Paul Ridker, a cardiologist at Brigham and Women’s Hospital and the Harvard Medical School, was that many of these individuals had in their bloodstream high levels of a substance known as C-reactive protein (CRP), which was closely linked with inflammation. Ridker had long suspected that inflammation played at least a principal part in the pathology of serious cardiac events.

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A closer look at what actually happens

Paul Ridker followed up his discovery about CRP with a study in which it was shown that treatment with statins not only lowered cholesterol levels, but also lowered levels of this inflammation marker. And in 2008, Ridker presented the results of the JUPITER trial at the New Orleans meeting of the American Heart Association. (Ridker P et al. New Engl J Med 2008;359:2195-2207)

This large trial (17,802 subjects) compared two cohorts of persons, all of whom had normal cholesterol levels. One group of 8,901 subjects received 20 mg. of rosuvastatin daily, and the other, also 8,901, got the placebo. The primary endpoint was incidence of cardiac events consisting of nonfatal myocardial infarction, nonfatal stroke, unstable angina, or death from cardiovascular causes. Subjects receiving rosuvastatin experienced 142 such events, while those on placebo experienced 251 events. Although the reduction was small in terms of absolute risk – about 1.2% ― it was considered highly significant, both statistically and in terms of implications for treatment. As a result of these results, the trial was stopped after a bit less than two years because the sponsors considered it unethical to continue a large cohort of patients on placebo when significant benefit had been demonstrated in the treatment arm.

The subjects in the JUPITER trial had baseline LDL-cholesterol levels of 108 mg/dL and CRP levels of 4.2/4.3 mg/L. Those LDL-C levels are considered reasonably good in patients with no established cardiac risk factors. However, CRP levels greater than 4.0 mg/L are now considered elevated and associated with significant risk.

The JUPITER trial cannot be said definitely to demonstrate that lowering CRP was the determining factor in reducing the numbers of signal cardiac events. Treatment with rosuvastatin not only reduced CRP from the baseline level to about 1.8 mg/L, but also lowered the LDL-C levels from a pretreatment 108 mg/dL to 55 mg/dL, so the benefit may have in part been due to the LDL-C reduction. But the reduction in that marker of inflammation was certainly an eye-opener.

In further analysis of the JUPITER trial results, Ridker came to the conclusion that elevated CRP levels signal more heart disease risk than do elevated LDL-C levels, although the highest risk is in patients in whom both of those are elevated. CRP levels below 1 mg/L are related to low risk, between 1 and 3 mg/L to medium risk, and higher than 3 mg/L to higher risk. The chart below traces the relationship between LDL-C and CRP levels and cardiac risk over an 8-year period.

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Here’s another way of looking at the way cholesterol and inflammation (as shown by CRP levels) have a causal relationship with cardiac events.

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According to the data behind that chart, a person could have a relatively high level of LDL cholesterol, such as greater than 160 mg/dL, and not be affected by a high level of cardiac risk. A person with elevated levels of CRP, indicating systemic inflammation, would be likely to have a higher level of cardiac risk even if his/her LDL cholesterol level was moderate, lower than 130 mg/dL. But if both the LDL cholesterol and the CRP levels were in the highest range, the cardiac risk would be apt to be very high indeed.

The LDL-C levels considered as low in these graphics are based on the guidelines promulgated by the National Cholesterol Educational Program (NCEP) Adult Treatment Panel III in 2001, which used 130 mg/dL as the cutpoint for borderline high LDL-C. More recently, many clinicians have argued for a target LDL-C reading of about 100 mg/dL in individuals with no specific cardiac risk factors, and below 70 mg/dL in persons with one or more risk factors. Thus, the data above could be criticized as minimizing the risk presented by elevated levels of LDL-C.

Although the data as presented strongly suggests that inflammation is a greater risk factor for heart disease than elevated cholesterol, it is far from presenting satisfactory vindication for the supporters of the view that inflammation is the whole story and cholesterol is a mere ruse cooked up by the pharmaceutical industry as a way to push their products.

Interaction between cholesterol and inflammation

We can accept the data showing the link between cholesterol and inflammation, on the one hand, and serious cardiac events such as heart attacks and strokes on the other hand. The statistical link is evident. But how exactly does inflammation cause these cardiac events? And why is it that the cholesterol that lodges in our arteries becomes the blood clots that cause strokes and myocardial infarcts?

At about the same time that Paul Ridker was doing his preliminary investigations , another Brigham and Women’s/Harvard cardiologist, Peter Libby, learned that cholesterol didn’t just swim around in the bloodstream. It actually worked its way into the arterial wall. This appeared to constitute a kind of insult to the arterial wall and provoked an inflammatory response, which in turn resulted in the formation of blood clots. It was these blood clots that, at least in some cases, blocked coronary arteries, causing heart attacks, and also blocked cerebral arteries, causing strokes. Peter Libby coined the term “vulnerable plaque” for plaque affected by inflammation that was prone to clot formation.

Libby demonstrated that the interior walls of blood vessels are made from smooth muscle cells which are lined with the endothelial cells that are in direct contact with the circulating blood. These endothelial cells act as sentries. If they detect the presence of anything other than blood cells in the blood stream, they summon white blood cells, which are the immune system’s front-line guardians. Naturally occurring adhesion molecules could attract the white blood cells and get them to stick to the endothelium lining the arteries. This action triggered an inflammatory response in the arteries, and the release of a cytokine called interleukin-1 (IL-1). IL-1 had been discovered in the late 1970s, and which had been found to cause fever in laboratory animals. IL-1, classified as a pyrogen (a fever-causing agent) is considered fundamental in the inflammatory process. Libby found that IL-1 could be produced in the lining of arteries, and that it actually amplified its signal at that site.

The actual physiologic mechanism that caused these cardiac events became better understood because of the work of Libby and Ridker. It has been very reliably confirmed that the substance in arterial plaque was cholesterol, and that blood clots containing particles of this plaque, were the material causes of MIs, strokes, and other signal cardiovascular events. What had not been completely understood prior to the research conducted by Libby and Ridker, their colleagues and numerous other medical researchers, was what happened in between cholesterol synthesis and arterial transport of cholesterol by lipoproteins, and then, at the other end of this pathophysiology, when cholesterol was absorbed into the arteries and then released in the form of potentially lethal clots.

We could state their conclusion this way: cholesterol is the missile, and inflammation is the fuel that propels it.

Ridker and Libby, along with many others, confirmed this in a large trial conducted in 39 countries and involving 10,061 subjects, all of whom had previously sustained a myocardial infarction and had a CRP level in excess of 2 mg/L, which is well above the normal range but not at a particularly high level. The purpose of the trial, named CANTOS, was to confirm the hypothesis that reducing inflammation without affecting lipid levels would result in lowering the risk of cardiovascular disease. (Ridker PM et al, N Engl J Med 2017;377(12):1119-1131)

The active agent being used in this trial was canakinunab, a therapeutic monoclonal antibody targeting interleukin 1β, one of two forms of IL-1, the fever-causing cytokine whose release was triggered by the attachment of white blood cells to the surface of arteries. Canakinunab, whose trade name is Ilaris (Novartis), is approved for a range of uncommon autoimmune diseases including cryopyrin-associated periodic syndromes (CAPS), active systemic juvenile arthritis, and others. These diseases are inherited and frequently affect children as young as one year of age.

The CANTOS trial compared three doses of canakinumab (50 mg, 150 mg, and 300 mg, given subcutaneously every three months) with placebo. The primary efficacy endpoint was nonfatal myocardial infarction, nonfatal stroke, or cardiovascular death.

At each of the three dosage levels, subjects in the canakinumab group sustained fewer cardiovascular endpoint events than those in the placebo group. At 3.7 years into the trial, the incidence rate in the placebo group was 4.5 cardiovascular events per 100 patient-years, while those in the 50 mg, 150 mg, and 300 mg canakinumab cohorts were 4.11, 3.86, and 3.90 per 100 patient-years. Only the differences in the 300 mg group were statistically significant for the primary and secondary end-points compared with placebo. The incidence of all-cause mortality was 15% lower in canakinumab-treated subjects than in the placebo group.

While the reductions in risk were not clinically meaningful, the CANTOS trial convincingly demonstrated that targeting the IL-1β pathway could lead to a significantly lower rate of recurrent cardiovascular events, independent of any therapy directed to cholesterol lowering.

The CANTOS research team went on to examine the effects that an anti-inflammatory strategy might have on diseases unrelated to cardiac disorders. Reports of gout and arthritis fell significantly, and lung cancer incidence fell by 77%.

The CANTOS trial did not seek to validate canakinumab as a form of therapy for the prevention of cardiovascular events. For one thing, the drug is exceedingly expensive. A single subcutaneous dose of canakinumab costs about $16,700. As a treatment for gout, for example, these would be required every two weeks. The rate of side effects with canakinumab was slightly higher than in the placebo group; neutropenia and thrombocytopenia being the most common.

What the CANTOS trial – along with other investigations of the possible role of inflammation in what are generally considered to be unrelated diseases – does is give an impetus to investigations of the ways in which inflammation may contribute to apparently unrelated diseases in virtually any part of our bodies. Evidence has gradually been accumulating suggesting possible involvement of inflammation in such conditions as Alzheimer’s Disease, cancer, asthma, gout, psoriasis, anemia, Parkinson’s disease, multiple sclerosis, diabetes, and depression. But to go from the suggestion of possible involvement to clear demonstration of a causal relation will require extensive – and expensive! – clinical trials.

… so, going back to our point of departure …

What does all of this say about dietary cholesterol, which is cholesterol that has already been formed before we bring it into our digestive system – cholesterol in meat, eggs, dairy products, and even some grains?

I can assert with considerable confidence that what the word “cholesterol” means to a huge number of people – perhaps even to some of you in the Gumshoe community – is the bad stuff in meat, eggs, etc. And therefore, since in the past few years, if we’ve paid much attention to the proclamations of many medical and health organizations, we may have come around to the position that cholesterol isn’t the problem, because those organizations have eased back on their dietary recommendations. They have instead doubled down on more generalized “healthy lifestyle” recommendations – the Mediterranean diet and DASH (Dietary Approaches to Stop Hypertension)-style diets. Obesity – rightly! – is the bugaboo. The 2013 AHA/ACC Guideline on Lifestyle Modification to Reduce Cardiovascular Risk” did not include a recommendation for dietary cholesterol and concluded that “There is insufficient evidence to determine whether lowering dietary cholesterol reduces LDL-C (low-density lipoprotein cholesterol.” The Dietary Guidelines Advisory Committee (part of NIH) stated in its 2015 recommendations that they would not bring forward their previous recommendation to limit dietary cholesterol “because available evidence shows no appreciable relationship between consumption of dietary cholesterol and serum cholesterol.”

So what accounts for the big switch, with the AHA’s science advisory making these statements:

“Given the relatively high content of cholesterol in egg yolks, it remains advisable to limit intake to current levels. Healthy individuals can include up to a whole egg or equivalent daily. A 3-oz serving of shrimp is equivalent to about a whole egg. Shrimp and other shellfish can be incorporated into a heart-healthy dietary pattern when paired with other lean or plant-based protein sources. Caveats exist for the following subgroups:

  • Vegetarians (lacto-ovo) who do not consume meat-based cholesterol-containing foods may include more dairy and eggs in their diets within the context of moderation discussed herein.
  • Patients with dyslipidemia, particularly those with diabetes mellitus or at risk for heart failure, should be cautious in consuming foods rich in cholesterol.
  • For older normocholesterolemic patients, given the nutritional benefits and convenience of eggs, consumption of up to 2 eggs per day is acceptable within the context of a heart-healthy dietary pattern.”

That strikes Doc Gumshoe as a considerable restriction on dietary cholesterol. A three-ounce serving of shrimp or one whole egg for healthy individuals? For older persons (why call them patients if their cholesterol is normal?) two eggs a day is okay as long as they stick to a heart-healthy diet.

I am prepared to venture a guess. My conjecture is that the medical community has been observing, with a mixture of satisfaction and disapproval, that a very large number of people are indeed taking statins, and that by and large, the statin regime controls their cholesterol levels fairly well. But – here comes the disapproval part – once having brought their total and LDL cholesterol down to acceptable levels, these individuals aren’t paying a whole lot of attention to their diets. Yes, it has been impossible to establish a link between dietary cholesterol in isolation and cardiac problems. But the link between total cholesterol – or specifically the low-density to high-density lipoprotein cholesterol ratio – and heart disease has been definitively established. And there’s no doubt that dietary cholesterol contributes to the total cholesterol burden – perhaps not more than 15% or 20%, but those modest fractions could raise the cholesterol level past the safety point, at least in some individuals.

It may be that a return to somewhat stricter recommended limits on dietary cholesterol are a tribute to the success of statins.

* * * * * * *

Speaking now from a personal perspective, as your faithful Doc Gumshoe, what strikes me about this business of guidelines, whether from the American College of Cardiology, the American Heart Association, the Dietary Guidelines Advisory Committee, or any other august body, is that the very act of formulating guidelines is fraught with uncertainty. As I read the guidelines, I get the definite impression that they are skating on thin ice, and they know it. Their guidelines are full of caveats, as they need to be. The AHA acknowledges, albeit in microscopic print, that their so-called “data” about what people actually eat comes from either food-frequency questionnaires, or 24-hour dietary recalls. In other words, not controlled, and not even observational, but relying on the memory and reliability in their subjects. And in arriving at their dietary guidelines, they categorize the entire population into four bunches – healthy individuals, vegetarians, people with dyslipidemia, and older people. I can’t imagine how many categories it would take to cobble together recommendations that would be right for the entire population, but those four aren’t nearly enough.

My guess is that most health-care professionals will pay only a tiny bit of attention to those AHA recommendations.

Thanks for all the comments – keep them coming! Best to all, Michael Jorrin (aka Doc Gumshoe)

Ed. Note: Michael Jorrin is not a doctor, though I dubbed him “Doc Gumshoe” many years ago. He is a longtime medical writer who shares his thoughts with our readers a couple times a month. His articles generally do not focus on investment ideas, but he has agreed to our trading restrictions. You can see all of his past commentaries here.

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mvvdoc
mvvdoc
January 16, 2020 12:04 pm

The statins have significant side effects especially in the elderly. I stopped taking Lipitor at age 90. Since then,now 94, my LDL and HDL levels are as before , borderline, and fortunately the side effects have disappeared .
Mvdoc

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Chuck
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Chuck
January 16, 2020 1:53 pm
Reply to  mvvdoc

Statins are dangerous, and often come with many side effects that are worse than the problem they are trying to correct! Friends that quit taking them talk of increased stamina, no ED problems, blood pressure is better, and more.

The other fact is that the blood pressure guidelines do not apply to everyone. There are family histories with out of sight 4-5-600 cholesterol readings, and NO HEART DISEASE problems into their 80’s and 90’s. It is not a one size fits all guideline.

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GeneH
GeneH
January 16, 2020 4:51 pm
Reply to  Chuck

I had a ‘mild’ heart attack which resulted in a stent and 80 mg statin prescription. After a year of headaches, I complained to my doctor, and while monitoring my cholesterol levels, have managed to lower my statin intake to 10mg daily.
I’m happy to say that the headaches disappeared, and my cholesterol levels are excellent in spite of the greatly reduced statin intake.

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Joseph Passofaro
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Joseph Passofaro
January 16, 2020 12:20 pm

Excellent article. As a degreed nutritionist, I know it is very difficult to pinpoint dietary guidelines for broad sections of the population. The Mediterranean and DASH diets are more general recommendations towards a healthy lifestyle that can benefit nearly any population or group of individuals seeking to improve their health through diet. Thank you for spreading the word and showing the research behind the hype.

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Larry Johnston
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Larry Johnston
January 16, 2020 12:27 pm

Its all about the money. Re: Original Jupiter Study- In the statin group, there were 141 major cardiovascular events
versus 251 in the placebo group”. If one took a statin, they had a 98.4 percent chance of not having a
cardiovascular event, versus a 97.2 percent chance of not having an event when taking the placebo. There is
only a 1 percent difference in cardiovascular events if normal, everyday Math is applied. Stats based on this myth of 50% reduction are all Bs. Statins are not only not very helpful but they’re actually harmful.

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revalidate
January 16, 2020 3:32 pm
Reply to  Larry Johnston

Agreed. There have been several books written about this, including “The Cholesterol Myth.” Lipitor has been the best selling drug sold, and I believe it has been a far more financial benefit to the Pharmaceutical and Medical community than a health benefit to it’s consumers.

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Julian Satran
Member
January 20, 2020 6:09 am
Reply to  revalidate

I think that is part of that the numbers show without a doubt that statins have helped and asking whom it has helped more is comparing apples with oranges. I was not an early investor in statins but I wish I would have. been. As for books only a few of them claim to hold the “absolute truth” and I doubt those are 🙂 I wish a discussion about the “next statins” in this forum could help us see them early and not judge them late.

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Julian Satran
Member
January 20, 2020 5:54 am
Reply to  Larry Johnston

The way I read the math a reduction from 2.8% events to 1.8%events is a 36% percent reduction and not a 1% reduction. 1% is the increase in the number of healthy people and we know that most people are healthy. But don’t let numbers confuse you 🙂

C.E. Colson
Member
C.E. Colson
January 21, 2020 10:00 am
Reply to  Julian Satran

Going from 2.8% down to 1.8% is, indeed, a 36% RELATIVE reduction, but only a 1% decrease in frequency or likelihood. To look at it another way (and the way that is most meaningful for you as a patient), only 1 person in a hundred will benefit from this treatment.

Austin Gardiner
Austin Gardiner
January 16, 2020 12:43 pm

I know that my experience is a sample of 1, so statistics don’t count.
There is heart disease in my family.
My mother a life long non smoker non diabetic careful eater etc etc had a MI at 51…she always had a low HDL which is less common in women.
I had a MI in 1988, my HDL was low also, not super low, but mostly 38 to 41 or so.
I tried many things, vegan diet, was on the Ornish regime before his book came out (just random), took statins…but my HDL always stayed low and my triglycerides we always highish.
Until one day about 10 years ago, I cut out carbs and sugars and happened to do bloodwork, and my HDL was 74….I did not believe it, so a few months later on my low carb diet I repeated the test…77.
So I have continued on a low carb diet, my HDLS typically are between 80 and 90, my triglycerides are usually around 45 and my CRP is undetectable. I only started CRP testing after the HDL boost, so I don’t know what it was at the time of my MI, but since going low carb it has always been <0.2, the sensitivity limit of the test.
I eventually stopped statins, was nervous about it of course…this was somewhere around 6 or 7 years ago. My CRP is still undetectable, my HDL is still around 80 to 90.
I can still run, climb mountains, cycle long distances.
No cardiac events.
Low carb in my opinion works for me.
Anyone with low HDL and other signs of the metabolic syndrome should try a low carb diet and after a few months test their HDL and CRP. If you are taking meds to lower your blood sugar, then you need to be careful about hypoglycemia, but compared to other interventions dietary modifications are pretty safe.
This is just my experience, but it was dramatic.

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Rebecca M
Member
Rebecca M
January 16, 2020 1:17 pm

That is awesome, Mr. Gardiner! Low carb works in my family also. Ultimately, however, I am most interested in the work of Dr. Georgia Ede, a Harvard trained psychiatrist who blogs about how plants use a myriad of chemical defenses to deter animals from eating them. Some of these chemicals found in brassicas and soy can affect our thyroid. I don’t think the discussion about heart health is complete until we know how a thyroid under siege from a diet chosen in good faith can affect the heart. Dr. Ede blogs at diagnosisdiet.com and has a monthly column in Psychology Today.

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drdevious
drdevious
January 19, 2020 4:08 am
Reply to  Rebecca M

I must disclose I am an internal medicine physician and I can honestly tell you cutting out foods with high ratios of sugar and products containing high fructose corn syrup will amount to a higher return on your weight loss efforts, combat of fatigue, and simultaneously decrease risk of heart attack, stroke and dementia. I prescribe statins like candy because they work, unfortunately at least 10% quit due to side effects, probably 40% of patients prescribed statins don’t tell their doctor they don’t take it, or only when they eat junk food and feel guilty.

The major winners on statin therapy are heart attack survivors who are religious about their statin usage because they literally WILL have another heart attack if they don’t start exercising, quit eating more than their body can use in a day, and avoiding sugars! Having some muscle cramps is a small price to pay to prevent a heart attack which, if you’ve ever had one is an ordeal worth experiencing… let’s just say spending a week without sleeping in the hospital being poked and prodded for blood draws twice a day, being cut into to place a stent PCI or have a major surgical open heart bypass CABG (which we do if you’ve got plaque in more than 1 artery or 1 major artery). The rehab is 6 months… so I’d stop complaining of a little cramp and headache side effect from statin for saving life. There are docs who joke about putting statins in water just like flouride! Personally, I think added sugar should be illegal. It would do so much more for humans and the environment.

Key point sugar is inflammatory. There are so many ways to be inflamed, we shouldn’t be adding new ways to be inflamed but we do… Americans produce and consume more sugar than most the world combined.

Inflammation causes clots which are the cause of STEMI, a real killer. Doc Gumshoe did a great job pointing out that cholesterol is just the fuel packed into the plaque of the artery, and the inflammation is literally the ignition of that fuel to cause a clot blocking the artery of the heart causing a heart attack.

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millionsilver
Member
January 16, 2020 1:03 pm

I don’t mean to slight your presentation, but, I read this long essay expecting to get a question at the end–and I don’t see one.

The issue of fatal heart disease and cardiovascular health is important to me. I lost my best friend (who was obese) to a fatal heart attack at the age of 46; and my paternal grandmother had a triple bypass surgery (I’m assuming for clogged arteries) in her 80s. She is now 96 and still going.

I think most of this so-called research is politically/economically motivated, and suspect at best. However, I’m willing to accept the thesis that if a person has higher bad cholesterol and higher than normal CRP (or inflammation causing agents) then that person may be at an elevated risk for a heart attack or stroke.

However, if a person is in that situation, what is he or she supposed to do about it? What is your conclusion on that, and which evidence do you base your conclusion?

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Austin Gardiner
Austin Gardiner
January 16, 2020 2:15 pm
Reply to  millionsilver

You should try a low carb diet and see what happens to your HDL and CRP…if the change is good, then consider this a new life style.
You know that silver and palladium have some things in common, not many primary mines and embedded in technology. What palladium has done because it was a cheap substitute for platinum is a thing of the past, but it takes a lot of incentive to switch back to cheaper platinum. One day silver will do the same, only when is anyones guess, but 1981 to 2011 is 30 years which is a commodity period often mentioned…2041? lol
I could not resist because of your name.

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hlawler
hlawler
January 16, 2020 2:57 pm

I agree with you on the low carb diet. I have done this for about 8 months now. My health is greatly improved as well.

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millionsilver
Member
January 16, 2020 3:22 pm

I don’t know why on earth you suggested I go on a low carb diet… but for what it’s worth I have been eating low carb for 15 years and going. So you’re completely off point. Also, I wrote about silver which was featured on this website a few weeks ago and you did not comment.

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HugoTheImpaler
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HugoTheImpaler
January 16, 2020 4:16 pm
Reply to  millionsilver

I don’t get why you believe any study on this topic is “politically” motivated.
Financial YES!
Political ??

millionsilver
Member
January 16, 2020 7:43 pm
Reply to  HugoTheImpaler

I made that claim because all of the large health organizations that get the lion’s share of the mainstream press are political in nature and their fates and fortunes rise and fall as a result of lobbying and legislation. Call me jaded.

wendy
wendy
January 18, 2020 1:19 am
Reply to  millionsilver

Drug company’s can promote the “white papers” that show their drugs as good/safe, etc. but hide the side effects in very small print on their published papers. I tried statin drug for a very short time, but at the same time, I went to an MD / Naturopath physician that specializes in anti-aging. Now, I’m taking RegeniFREE -with all natural anti-inflammatory compound.. including Turmeric. My bloodwork is impressive HDL level unbelievably excellent now ! Another option besides a specialized physician – some of the Natural Supplement shops have a Nutritionist or Naturopath on their payroll from time to time. Call to find out if they have an expert to meet with on the subject of Natural options for choesterol – reducing inflamation in your body (which seems to be causing so many diseases). My dad died at 35, so I’ve been studying all options for years. And of course, being overweight, bad diet, lack of real foods – fruits & veges, and lack of excercise = just asking for trouble. That’s my 2 cents. Thanks for sharing!

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Chuck
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Chuck
January 16, 2020 1:46 pm

The thing that appears to be overlooked is the differentiation between saturated and polyunsaturated fats. The AHA was begun as the front man for the polyunsaturated sales pitch in the thirties by the food industry, and the Heart Healthy campaign ads. A lot of BS. Go to Weston Price Foundation to get the real truth about these fats, The Oiling of America. The incriminating evidence is overwhelming, and the reason they backed off the old guidelines. Prior to the introduction of poly’s in the 30’s, CVD/CHD was not an issue in the medical books.

Saturated fats are beneficial and necessary, period. These can be broken down by the body. Polyunsaturated, or any of the hydrogenated oils are the real demon. The molecular structure was changed by the high heat extraction process and cannot be broken down in the body. Want quick proof? Pull out that old bottle of poly crap in your pantry. Check the top and lid. It’s sticky. Over time, this bad fat accumulates like glue or resin in the arteries and heart. Naturals like olive, palm, butter don’t really go bad, just rancid. They are liquid at room temps and in the body.

Got divorced over this issue. I ate only saturated fats, ate what I wanted, smoked, didn’t exercise regularly. She ate only polys, avoided sats like the plague, exercised heavily 4 times a week. My cholesterol was always an easy 10-20 points lower than hers. Pissed her off immensely, and we argued a lot about it. She couldn’t handle the truth, followed the AHA line of BS. She’s since had two open heart surgeries. Me, still the perfect patient 40 years later, and I haven’t changed my bad or good habits.

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bwa123
bwa123
January 16, 2020 2:20 pm

FMD, Fast Mimicking Diet, Dr Valter Longo. Prolon. Life changing. But, difficult to monetize, so not very promoted, nor known.

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KENDRICK MILLER
Member
KENDRICK MILLER
January 16, 2020 2:26 pm

Doc,
Most US Dr.s still recommend statins for patients whose cholesterol exceeds guidelines even if they have had not cardio events, or cardiovascular disease.
This behavior reflects the US medical establishment’s continued adherence to Allopathic medicine. That is the belief that “modern” synthetic chemistry can synthesize cures. The belief is false. At best synthesized drugs may reduces symptoms, but often with adverse side effects. This is the case with statins which were justified based on deceptive statistics.
Statin research indicated a reduction of 50% is cardiac events, or a 100% improvement, depending how you calculated the percentage. That sounds wonderful. But this is hugely deceptive!
The actual raw data indicated for every 202 patients taking statins, the cardiac event fell to one event compared with the placebo control which experienced two events. So cardiac events fell 50%, but the overall rate was 1/202=.0049. Such is the statistical deception of clinical research, when drug companies seek to justify their “products”.
And what about the 201 patients on statins? They developed the well known side effects, muscle problems, mineral deficiencies, liver damage, kidney damage neurological damage, increased asthma symptoms, possible chronic diseases (diabetes etc.), even heart disease itself, etc.
Statins may have a role to play in some patients who have already had a major cardiac event, or those with an inherited mutation in their cholesterol production, but they are definitely inappropriate for those of us with moderately “elevated” cholesterol. In most cases your body is producing the cholesterol it needs for critical cellular functions and the liver probably adjusts its production for food sources of cholesterol.
There are a lot more serious things than cholesterol to worry about in our food supply.(e.g. pesticides, untested GMO, herbicides, microplastics, bacterial and viral pathogens, parasites, etc.)

Kendrick Miller

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texasranger
texasranger
January 16, 2020 3:02 pm

Another sample of 1. Have had high cholesterol all my life as does my 97-year-old mother and don’t take meds. Started the celery juice craze about 9 months. Chol down 28%, Tri down 38%, HDL up 5%, LDL down 34%. Can’t prove that taking 16oz of pure celery juice every morning is the reason…but nothing else has changed.

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Hannibal Smith
Member
Hannibal Smith
January 23, 2020 6:40 pm
Reply to  texasranger

Not hard to figure out why. Celery contains nitrates which boost nitric oxide production in the endothelium walls. There is an inverse relationship between oxidized cholesterol and nitric oxide. There are easier ways to get this effect on an ongoing basis than the risk of nitrates turning into carcinogenic nitrosamines though.

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revalidate
January 16, 2020 3:28 pm

I have a high cholesterol rate (above 200), but I exercise vigorously and often (tennis), I eat a healthy diet, which includes meat, vegetables, eggs, and some dairy. I avoid sugar for the most part, and I don’t smoke or engage in heavy alcohol drinking. My BMI is in the optimal range of 25 to 30.
My blood pressure is in the 120/85 range, and I don’t have a family history of heart disease.
I don’t take statins and I doubt I ever will.

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hedy1234
hedy1234
January 16, 2020 3:45 pm
Reply to  revalidate

The optimal BMI range is UNDER 25…..

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C.E. Colson
Member
C.E. Colson
January 17, 2020 8:38 am
Reply to  hedy1234

The “officially-stated” optimal range for BMI is 20 <25. HOWEVER, actual studies (as opposed to dogma) find that people in the "slightly overweight" range of 25 < 30 are the healthiest, followed by those in the overweight (30 < 35) and normal (20 < 25) ranges, who are about the same. As is so often the case, the "medical" guidelines we are given are often guided more by "religion" than by scientific finding.

Yep
Yep
January 16, 2020 3:59 pm

My two cents worth. In May 2017 a heart cath showed I had 3 arteries 90-95% blocked (including the LAD), the RCA was 100% blocked (“gone” the surgeon said), and another artery 65% blocked. I had a burning pain in my chest 24/7 and a quadruple bypass was recommended. For several medical reasons I never had the surgery and immediately started on Dr. Caldwell Esselstyn’s plant based diet, thereafter entered Dr. Dean Ornish’s cohort program and follow both Drs. recommended programs to this day. The pain in my chest went away within 2-3 weeks, I feel great, have more energy, lost 40 pounds and eat all I want, and my cholesterol and inflammation numbers are incredible. The only medication I take is the recommended baby aspirin once per day. A plant based diet, exercise, and stress reduction works for good health and longevity. And frankly, it’s simple to follow if you educate yourself and stick to a plan.

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Karl
Member
Karl
January 16, 2020 4:10 pm

Dr Linus Pauling discovered that inflamation in blood vessels is caused by inadequate levels of vitamin C, which alowed the blood vessels to crack and leak , the extreme case being scurvy. Fibrin is used to plaster over those cracks and cholesterol gets caught in the fibrin,
which leads to hardening of the arteries , high blood pressure, and MI due to rupture of the placques. Vitamin B6, C, and magnesium are also essential in managing cholesterol, keeping the arteries clean, and delivering cholesterol to the cells where it delivers its load of oil or fat for the cell to convert to energy or other cell structures. Copper is also essential to blood vessel elasticity. Most people do not get adequate amounts of nutrients without supplementation. The B vitamins, C, and magnesium are all water soluble and usually thrown away after vegetables containing them have been boiled, and most B vitamins are found in meat, particularly organ meat, mushrooms, and wheat germ, which many folks avoid. Statins are not a substitute for proper nutrition and destroy CoQ10, which is essential to brain and heart health.
Most other animals produce vitamin C in their livers, so do not suffer from cardiovascular disease, but man and the Guinea pig do not produce vitamin C, so both are susceptible. Also, the liver makes cholesterol to carry fats to the cells, and also breaks it back down with the aid of vitamin C. So, inadequate vitamin C can cause higher cholesterol levels. Finally, vitamin C is an anti-oxidant, which helps prevent the oxidation of cholesterol in the blood vessels, the oxidized cholesterol being the primary villian in arterial placques.

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Hannibal Smith
Member
Hannibal Smith
January 23, 2020 6:45 pm
Reply to  Karl

Vitamin C is weak at best for preventing oxidization of cholesterol (it is a lipid after all, and C is water soluble). Problem with debates on this topic is everyone is subtly shepherded into a “silver bullet” solution instead of a comprehensive approach because that is where the money is.

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baronkb
baronkb
January 16, 2020 5:20 pm

I was on statins, mostly maximum dosage for nearly 20 years when my Left Anterior Descending artery (the “widow maker”) was diagnosed as 95% blocked. So I required a stent to open the artery. I was fortunate that the blockage was detected as part of a routine physical and stress test. Otherwise I could have dropped dead like my father did in 1979. What statins did do for me is nearly cripple me with back spasm and pain so bad I was virtually paralyzed when they struck. I gave up statins entirely in 2009. Today, 11 years later, there has been no progression of arteriosclerosis in my cardiac arteries as verified by PET stress tests repeated every 2 years. I still have residual muscular effects from the statins in my lower back as well as 3 herniated discs thanks to weakening of the muscles on my spine that hold the discs in place. But I am able to exercise moderately, which I would never have been able to do while taking statins. I am now on Praluent which has dropped my total cholesterol from the 290s to 116. My LDL cholesterol is in the low 50s. I have no side effects from the Praluent. Bottom line is I believe the entire statin mess was simply a money-making machine that took red rice yeast in its natural form and exploded it into statins. Praluent now is unaffordable at the retail price and I receive it via a subsidy as my income is a couple of thousand dollars below the maximum allowed. So if the medical community was really serious about reducing cholesterol, Praluent would be made available at reasonable, affordable prices for all. Otherwise, the intent of the cholesterol lowering mantra is nothing more than a scam.

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dunnydame
dunnydame
January 16, 2020 7:23 pm

Thanks for another interesting article, Sr Jorrin, aka Doc Gumshoe.
I looked back at my latest test results from 3 weeks ago and couldn’t find a mention of C-reactive protein (CRP) being measured and reported.
Is it the same as the Chol/HDL-C ratio? (That number was given as 2.8 for me.)
Or is it something that I have to ask specifically to have included in the blood work report?
Also, seeing that there does seem to be a link between cholesterol and inflammation, and serious cardiac events such as heart attacks and strokes, have you come across any studies with findings about the effect of inflammation from dental causes?
Thank you again,
Penny (who is grateful for her excellent cholesterol numbers)

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Hannibal Smith
Member
Hannibal Smith
January 23, 2020 6:49 pm
Reply to  dunnydame

CRP has to be specifically tested. It’s a separate risk marker. Keep in mind all of these measurements are markers, not causation. True causation is oxidized cholesterol that starts the ball rolling downhill. Prevent that from happening and you prevent the downstream effects.

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millionsilver
Member
January 16, 2020 7:44 pm

I don’t know who the author of this essay is, but I hope he will answer the questions I posted this morning. Or this is turning out to be a massive waste of time.

jabel
Irregular
jabel
January 17, 2020 2:39 am

Have there been no significant trials on just diet-related health/disease issues? If not, why not? As there should be on a controlled exercise regime? Clearly no drug -related funding here, but the health community are not all funded by drug companies, are they?

Hannibal Smith
Member
Hannibal Smith
January 23, 2020 6:53 pm
Reply to  jabel

Costs a lot of money to do such comprehensive trials so very few have been done to date. Money is not the only way Big Pharma has a deathgrip against alternative/preventive medicine, there is mindshare, regulatory capture, career risk and many other unsavory tactics.

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Hannibal Smith
Member
Hannibal Smith
January 23, 2020 7:04 pm

Well, if you’re sticking to the biased data that predominates medical research, then the benefit of statins is only marginal and not warranted for people that aren’t within the study purview which is almost always those that already had a heart attack, i.e. the sickly.

That being said, statins have anti-inflammatory action separate from its cholesterol suppressing abilities. You could use it off label for that purpose, but would that be a wise choice? If someone is not willing to make “radical” lifestyle changes in terms of cleaning up their diet, taking supplements, pumping iron, etc.. well…. you only get what you are willing to put effort towards.

Dealing with cholesterol is passe anyhow. The root problem is OXIDIZED cholesterol, not cholesterol per se. So a relatively smarter approach for the lazy wanting a “silver bullet” is PCKS9 inhibitors that specifically target only the LDL transporter instead of cholesterol. Instead of throwing the baby out with the bathwater, you’re just throwing out the soap with the bathwater. But I surmise there will still be life-altering, negative side effects because LDL transports many other critical bioagents than just [oxidized]cholesterol. It will just take a lot longer to show up.

BTW, kudos for not writing another predictable and eye-rolling article on the topic.

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sleeper54
sleeper54
January 18, 2020 1:03 am

“But as for me, I will stick with the data.”

It certainly would not be a ‘bad thing’ for individuals to try some of these various diet, drug, and lifestyle options . . .while of course respecting their real-world and personal medical guidance.

…tom…

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millionsilver
Member
January 18, 2020 11:21 am

Michael Jorrin,

Thanks for your answer, but I’m afraid my question was ambiguous. I didn’t ask if each of the conditions could be treated (which seems obvious). My question is do you accept the thesis that a person with elevated levels of bad cholesterol and CRP is indeed at higher risk for a heart attack or stroke? It seems to me you accept that thesis and that such a person should go under the care of a medical doctor (someone who can prescribe drugs)?

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Hannibal Smith
Member
Hannibal Smith
January 23, 2020 7:11 pm
Reply to  millionsilver

Along with 10+ other markers. Cardiovascular disease is not a result of a single cause but multi-factorial.

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photohobo
January 18, 2020 11:22 am

Nowhere does this article mention the effects of sugar and insulin resistance in causing heart disease. That is no surprise because none of the major studies cited here or nearly all others funded by industry or tax dollars do either. That is no accident. We now have at least 4 generations of people who have grown up believing cholesterol or saturated fats are bad for you, despite the fact that your body requires both. Follow the money folks. The sugar industry’s redirection campaign is probably the most successful public opinion manipulation scheme in history. The tobacco industry’s subterfuge pales in comparison. C-reactive protein is an indicator, not a cause. Follow the cause of inflammation, and it will lead you to sugar.

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