Eat Fat, Get Thin_Why the Fat We Eat Is the Key to Sustained Weight Loss and Vibrant Health
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There is still some data showing that high LDL is a problem, but it is only one of many other factors, not necessarily the most important one.58 I have seen many eighty-five-year-olds with cholesterol of over 300 mg/dl and normal HDL and triglycerides, with no heart disease at all and clean arteries. What they did find in the study of heart attacks and hospital admissions was not surprising if you understand the link between sugar, carbs, and heart disease. The pattern most associated with heart attacks was low HDL and high triglycerides (not the LDL level), which is caused by sugar and refined carbs.
Years ago I had a chance to snowshoe through the Berkshires with Dr. Peter Libby from Harvard, one of the world’s most renowned cardiologists. I asked about all these patients I had, especially women, who had cholesterol levels over 300 mg/dl but also had very high HDL levels and low triglycerides, were slim, and had no other heart disease risk factors. I wondered if I should treat them with statins. He said that there was no evidence I should treat them, even with their high cholesterol levels.
People with the lowest cholesterol as they age are in fact at highest risk of death. In a study of more than 3,500 elderly men, those with the lowest cholesterol had a 64 percent higher risk of death. Under certain circumstances, higher cholesterol can actually help increase life span. It’s all in the spin of the statistics and numbers. And it’s easy to get confused.
I have tested thousands of patients on statins. I measure particle size, and despite statins’ ability to lower total LDL, I often see very high LDL particle numbers and very small LDL particle sizes in these patients, the pattern most associated with heart attacks.
This is not to say that statins don’t work. In fact, they help prevent heart attacks in people, especially men under seventy, who have already had heart attacks. And they work slightly for middle-aged men who have many risk factors for heart disease, like high blood pressure, obesity, and diabetes. But for most people to whom they are prescribed—people who have never had a heart attack—they don’t provide real benefit and come with a whole host of side effects and risks.59
You might ask why then did the 2004 National Cholesterol Education Program guidelines expand the previous guidelines to recommend that more people take statins (from 13 million to 40 million), and why did they recommend that people who don’t have heart disease take them to prevent heart disease (known as primary prevention)? Could it have been that 8 of the 9 experts on the panel who developed these guidelines had financial ties to the drug industry? Thirty-four other non-industry-affiliated experts sent a petition to the National Institutes of Health to protest the recommendations, saying the evidence was weak. Having industry-funded scientists make the guidelines is like having a fox guard the chicken coop.
Worse, more recent guidelines from the American College of Cardiology and the American Heart Association have recommended that even more people take statins, based on a 10-year risk calculation. That means 56 million Americans could be taking statins, up from 43.2 million.60 Many experts challenge the assumptions made in these guidelines.61 Do we really think that heart disease is a statin deficiency? Shouldn’t we be addressing the root causes? Is there other research that contradicts these guidelines? When you look under the hood of the research data you find that the touted “36 percent reduction” in heart attacks attributable to statins means a reduction of the number of people having heart attacks from 3 percent to 2 percent. Yes, it’s a reduction, but not as big a reduction as it sounds. But drug companies would rather ignore the distinction between absolute risk reduction (1 percent) and relative risk reduction (36 percent) when they market their products.
That data also shows that treatment works only if you already have heart disease. In those who don’t have documented heart disease, there seems to be no benefit. A group of independent scientists (with no links to or funding from pharmaceutical companies) reviewed the data on the benefits of using statins for preventing a first heart attack (their review is known as the Cochrane Database Systematic Reviews). They found that researchers looking at heart attacks and deaths in the statin treatment studies were selective in what they reported; they didn’t report bad outcomes, and they included people who had already had heart attacks (even though they weren’t supposed to). The independent experts concluded that only limited evidence existed that statins could prevent first heart attacks, reduce health care costs, or improve quality of life. As they stated, “Caution should be taken in prescribing statins for primary prevention among people at low cardiovascular risk.”62 And yet 75 percent of statin prescriptions are for people at low risk.
In 1954, Darrell Huff published an influential book called How to Lie with Statistics. It seems to have been well read by many drug researchers.
UNTANGLING THE STATS ON STATINS
There is a little-known concept in medicine called NNT or “number needed to treat.” This is a way of looking at the real benefits and risks in research. An independent group of doctors and scientists who receive no industry funding have created a platform for reviewing the literature on various medical topics. Their work can be found at www.thennt.com. And they have taken a deep look at statins and their pros and cons.
What they report is a bit shocking considering the hype and passionate promotion of statins by most doctors. In patients with no preexisting heart disease who took statins for five years, no lives were saved. In that group, statins helped prevent a heart attack in only 1 in 104 people (1.6 percent). And they helped prevent stroke in only 1 in 154 (0.37 percent).63 Not a very effective drug. Worse, 1 in 10 people had muscle damage and pain, and 1 in 50 developed diabetes. More people were harmed than helped by the medication. So it seems the risks outweigh the benefits.
But what if you already have heart disease, or have had a heart attack? The results for those who take statins are better, but not much. Statins helped prevent death in 1 in 83 people who already had heart disease (1.2 percent); they helped prevent a nonfatal heart attack in 1 in 39 (2.6 percent); and they helped prevent a stroke in 1 in 125 (0.8 percent).64 One in 50 got diabetes and 1 in 10 had muscle damage.
Just to put that in perspective: If a drug works, it has a very low NNT (number needed to treat). For example, if you have a urinary tract infection and take an antibiotic, you will get nearly a 100 percent benefit. The number needed to treat is 1, because every person treated will benefit. But if you have an NNT of 104, like statins do for preventing heart attacks in 75 percent of the people who take them (those without heart disease), it is basically a crapshoot and the side effects are serious (muscle damage, diabetes, memory loss, and even sexual dysfunction).
Here’s what the NNT group had to say about the state of statin research: “Virtually all of the major statin studies were paid for and conducted by their respective pharmaceutical company. A long history of misrepresentation of data and occasionally fraudulent reporting of data suggests that these results are often much more optimistic than subsequent data produced by researchers and parties that do not have a financial stake in the results. Also, harm from these drugs is difficult to predict, partly because harms are often difficult to anticipate and are often poorly tracked. Such findings often come up years after new drugs have been on the market.”
Yet at a cost of more than $28 billion a year, 75 percent of all statin prescriptions are for unproven primary prevention. Simply applying the science over 10 years would save more than $200 billion in health care costs.
PREVENTING AND TREATING HEART DISEASE
So if lowering cholesterol is not the great panacea that we thought, and statins aren’t effective, how do we treat heart disease? And how do we make sure we have the right kind of blood cholesterol—high HDL, low LDL, and low triglycerides, and cholesterol particles that are large, light, and fluffy rather than small, dense, and hard?
Our current thinking about how to treat and prevent heart disease is at best misguided, and at worst harmful. Most doctors believe they are treating the causes of heart disease by lowering cholesterol, l
owering blood pressure, and lowering blood sugar with medication. But the real question is, “What causes high cholesterol, high blood pressure, and high blood sugar in the first place?”65 It is certainly not a medication deficiency.
Don’t go blaming your genes entirely, either. It is the environment working on your genes that determines your risk. What you eat, how much you exercise, how you deal with stress, and how your body handles environmental toxins66 are the underlying causes of high cholesterol, high blood pressure, high blood sugar, and therefore heart disease.
The EPIC (European Prospective Investigation into Cancer and Nutrition) study of more than 500,000 people in ten countries, published in the Archives of Internal Medicine, reviewed a subset of 23,000 people’s adherence to four simple behaviors—not smoking, exercising three and a half hours a week, eating a healthy diet (fruits, vegetables, beans, whole grains, nuts, seeds, and limited amounts of meat), and maintaining a healthy weight (body mass index of less than 30). In those adhering to these behaviors, 93 percent of diabetes, 81 percent of heart attacks, 50 percent of strokes, and 36 percent of all cancers were prevented.67 And the INTERHEART study, published in the Lancet in 2004, followed 30,000 people and found that changing lifestyle could prevent at least 90 percent of all heart disease.68
These studies are among a large evidence base documenting how lifestyle intervention is often more effective in reducing cardiovascular disease, hypertension, heart failure, stroke, cancer, diabetes, and deaths from all causes than almost any other medical intervention.69 A healthy lifestyle doesn’t only reduce risk factors such as high blood pressure, high blood sugar, or high cholesterol; it influences a fundamental biological mechanism—gene expression, which modulates inflammation, oxidative stress, nutrient levels, and metabolic function. These are the real reasons we get sick.
Disregarding the underlying causes and treating only risk factors is somewhat like mopping up the floor around an overflowing sink instead of turning off the faucet. When the lifestyle causes are addressed, patients are often able to get better without medication or surgery.
In order to control these key biological functions and keep them in balance, you need to look at your overall health as well as your genetic predispositions. Your genes, lifestyle, and environment ultimately determine your risks—and the outcome of your life.
The good news is that your genes are under your control if you feed them right and treat them right. The science of how food acts as information to turn on or off genes that control health and disease is called nutrigenomics. And many other things affect your gene expression and function besides diet, including stress and activity levels.
The biggest risk factor for heart disease is pre-diabetes or type 2 diabetes—diabesity. Diabesity, an insulin and blood sugar problem caused by high doses of sugar and refined carbs, now affects 1 in 2 Americans and 1 in 4 teenagers. I have written extensively about this problem in my books The Blood Sugar Solution and The Blood Sugar Solution 10-Day Detox Diet.
Right up there with diabesity as a top risk factor is inflammation. What causes inflammation?
A poor diet (high-sugar, refined carbs, processed food, low-fiber, etc.)
A sedentary lifestyle
Stress
Food allergies (like gluten and dairy)
Hidden infections (such as gum disease)
Toxins (such as mercury or pesticides)
Finding and addressing all the causes of inflammation is critical to preventing heart disease (and almost all the diseases of aging, including obesity, cancer, diabetes, and dementia).
Many of these factors are synergistic and at play at the same time if there is inflammation. I recommend that people undergo a comprehensive medical evaluation to see what their risk really is and evaluate the presence and causes of inflammation. For example, gluten sensitivity (not even full-blown celiac disease) can trigger heart attacks and death and is often undiagnosed.70
A major study done at Harvard found that people with high levels of a blood test that measures inflammation called C-reactive protein (CRP) had higher risks of heart disease than people with high cholesterol. Normal cholesterol levels were not protective to those with high CRP. The risks were greatest for those with high levels of both CRP and cholesterol.
There is another easily treatable risk factor for heart disease. There is a blood test that measures homocysteine (which is related to your body’s levels of the key heart-protective nutrients folic acid and vitamins B6 and B12). High levels of homocysteine trigger oxidative stress and inflammation, which may cause heart disease. It’s easily fixed by taking the right forms of folic acid, and vitamins B6 and B12.
GETTING THE RIGHT TESTS
There are special tests that can identify imbalances in blood sugar and insulin, inflammation, nutrient levels such as homocysteine (folic acid), clotting factors, hormones, and other factors that affect your risk of cardiovascular disease. If you want to test your overall risk, you can consider asking your doctor to perform the following tests. (To learn more about testing and how to interpret these tests, you can also download my free e-book, How to Work with Your Doctor to Get What You Need. See www.eatfatgetthin.com.)
Total Cholesterol, HDL (Good Cholesterol), LDL (Bad Cholesterol), and Triglycerides
Your total cholesterol should be under 200 mg/dl (this depends on your overall profile and risk factors)
Your triglycerides should be under 100.
Your HDL should be over 60 mg/dl.
Your LDL should ideally be under 80 mg/dl (although this matters less than the LDL particle number and size; see the following section on NMR and Cardio IQ test). This also depends on your overall profile and risk factors.
Your ratio of total cholesterol to HDL should be less than 3:1.
Your ratio of triglycerides to HDL should be no greater than 1:1 or 2:1; this ratio can indicate insulin resistance if elevated.
NMR Lipid Profile or Cardio IQ Lipoprotein Fractionation (Ion Mobility)
The NMR test (available from Labcorp) looks at your cholesterol under an MRI scan to assess the size of the particles; particle size is the real determinant of your cardiovascular risk. The Cardio IQ uses a different technology and is available from Quest Diagnostics. It is important to track this as you change your diet. These are really the only cholesterol tests you should have. You should have less than 1,000 total LDL particles and no more than 400 small particles (although ideally you shouldn’t have any!).
Glucose and Insulin Tolerance Test
Measurements of fasting and one- and two-hour levels of glucose and insulin after taking a 75-gram load of glucose help identify pre-diabetes and excessively high levels of insulin, and even diabetes. You can also just do a fasting and thirty-minute test after drinking glucose; this can be almost as good an indicator of diabesity. Your fasting sugar should be between 70 and 80 mg/dl and your one- and two-hour sugars should be less than 120 mg/dl. Your fasting insulin should be less than 5 and one- and two-hour insulin levels should be less than 30. Most doctors just check blood sugar and not insulin, which is the first thing to go up. By the time your blood sugar goes up, the train has left the station. Be sure to ask that your insulin, not just your blood sugar, gets measured.
Hemoglobin A1c
This test measures your average blood sugar level over the previous six weeks. Anything over 5.5 percent is high. Just measuring your fasting blood sugar is not enough to detect early problems.
Cardio or High-Sensitivity C-Reactive Protein
This marker of inflammation in the body is essential to understand in the context of overall risk. Your high-sensitivity C-reactive protein level should be less than 1.0 mg/L, and ideally less than 0.7 mg/L.
Homocysteine
Your homocysteine measures your folate status and should be between 6 and 8 micromoles per liter.
Oxidized LDL
This test looks at the amount of oxidized or rancid cholesterol in the blood. This should be within normal limits of the test. It is
available through LabCorp.
Fibrinogen
This test looks at clotting in the blood. It should be less than 300 mg/dl.
Lipoprotein(a)
This is another factor that can promote the risk of heart disease, especially in men. It is mostly genetically determined. It should be less than 30 mg/dl.
Gluten Antibodies
Testing IgG and IgA anti-gliadin and IgA and IgG tissue transglutaminase antibodies measures immune response to gluten found in wheat, barley, rye, spelt, and oats and can help you identify this hidden cause of inflammation and heart disease (and many, many other health problems). Any level of antibodies indicates you may have a reaction to gluten. Your body should not make autoimmune antibodies to gluten. There really is no “normal” level.
Genes or SNPs
Genetic tests may also be useful in assessing your heart disease risk factors. A number of key genes regulate cholesterol and metabolism:
Apo E genes
Cholesterol ester transfer protein gene
MTHFR gene, which regulates homocysteine