About a week ago I received an email from a reader in New York.
She asked a really good question. But, I wanted an expert to answer it.
The Back Story
She had just received a copy of the January 2012 "Beating Edge", the newsletter of the Cleveland Clinic's Heart & Vascular Program.
Here's what this New York reader wanted to know:
"I just received the Cleveland Clinics Heart and Vascular Newsletter this morning and its leading article was a short Q&A piece on cholesterol.
I know that Dr. Caldwell B. Esselstyn, Jr. has a long association with the Cleveland Clinic.
Below lies an excerpt from the newsletter:
"Have your cholesterol checked. And, understand how cholesterol works, recommends Cleveland Clinic heart surgeon Marc Gillinov, MD, and cardiologist Steven Nissen, MD.
Can you tell fact from fiction?
1. Diet is the most important factor in determining your cholesterol level.
False. Eighty percent of the body’s cholesterol is made by the liver. That means, only 20 percent comes from your diet. That’s why it is so hard to lower cholesterol through diet alone. By banning nearly all cholesterol from your diet, you might be able to reduce your total cholesterol level by about 20 percent. Understanding this can often make the choice to take cholesterol-lowering drugs easier. If you need to reduce your cholesterol by 50 percent, you cannot accomplish this through diet alone. You’ll need a good diet and the right medication."
She went on to say: I have no intention - or at least I don't think so - of veering from my Esselstyn fare but I am wondering what sense you make of the above... I feel like this flies in the face of claims made by others who have followed the Esselstyn diet and seen significant decreases in their LDL.
Her question: Do you have any thoughts on the above?
The Response from a Plant-Based Cardiologist
What would a cardiologist, who personally follows the Esselstyn diet, say about the answer given to the Diet & Cholesterol question in this newsletter?
I certainly wanted to know, so I asked a professional who has the knowledge & expertise to best answer this reader's question. He prefers to remain anonymous. I feel so privileged that he took the time to respond to this question. Thank you!
Diet's Effect on Cholesterol - A Plant-Based Cardiologist's Point of View
"I don't find fault with anything said, except that I think it is fallacious to say that because 20% of your intake is dietary, you cannot reduce [your cholesterol] by more than 20% by changing your diet.
This part is just plain wrong. As you can see from the discussion that follows the article, there is more hype than fact. Unfortunately, funding for nutritional research is miniscule.
The statement that 80% of your cholesterol is made by the body and only 20% comes from diet is based on the average (as measured in the population eating the Western diet) cholesterol production of 1 gm per day and the recommended dietary intake of cholesterol of 200-300 mg.
For many Americans, the daily intake of cholesterol is much higher. For those eating a plant-based diet, the intake is near zero. So the 20% is not representive of a population, but rather an average of very different nutritional choices. Several other logistical fallacies occur to me:
1) Population studies on humans who eat a plant-based diet with very low dietary cholesterol intake show some of the lowest intrinsic cholesterol levels. We have many studies on dietary modification showing that decreasing cholesterol intake can result in dramatic lowering of serum cholesterol level. So the implication that dietary modification is not effective beyond 20% is just wrong. I personally cut my total cholesterol from 209 to 136 and my LDL from 144 to 72 with just nutritional changes.
2) Relatively few (if any) studies of cholesterol regulation have been performed in vegans, so we don't have much information on the effect of this nutritional strategy on cholesterol synthesis. You can't extrapolate findings from studies of patients on a Western diet. This is one of my biggest pet peeves. The majority of the research we are doing is on a population that is (hopefully) irrelevant. Drugs and devices may lead to much different results in a study of vegans with heart disease (if you could find enough to study!).
3) The assertion that drug therapy of elevated cholesterol is more effective than nutritional changes focuses on a surrogate endpoint, that is, the cholesterol level, rather than clinically important endpoints like death, MI and stroke. Dependence on surrogate endpoints is one of Dr. Steven Nissen's biggest criticisms of drug and device studies. Statins have been shown to result in improvement in early MI and death rates, but they are not above suspicion for longer term adverse outcomes and there is a growing concern about the downside of life long administration. Several drugs have been removed from the market because they lead to higher death rates despite their beneficial effect on surrogate endpoints. We need to look at the the MI, death and stroke rates of nutritional changes, not whether they can decrease cholesterol by 20%.
That said, there is no question that statins have a role in the early treatment of unstable coronary disease, but it is likely not due to their cholesterol lowering effect, but rather on their anti-inflammatory and pro-endothelial effect. There may be much less powerful effects long term on mortality and MI rates (as well as other longterm adverse effects). There is much less data on that."
I'm so grateful for the balanced response this cardiologist provided to the important question of how diet can affect cholesterol--or more importantly, its effect on heart disease.
I certainly hope we can call on him again to share his expertise in questions of heart disease and its prevention--and the beneficial effects of a plant-based diet.
As always, I'd love to get your feedback on this excellent guest post!
If you have a personal success story to share--now is the time.
Final Note: If you haven't yet paid a visit to my new Facebook page: Happy Healthy Long Life - The Healthy Librarian you are missing out on a lot of "hot off the press" health & nutritional news. In the past 7 days I've posted over 30 new items. (Is that too much?) You can always google: happy healthy long life - the healthy librarian facebook to find me, too.
Just a sample of the topics posts:
- From Fred Hutchinson's Cancer Center: the effect of low-glycemic carbs on inflammation levels and its potential effect on cancer
- The effect of statins on diabetes in post-menopausal women
- An hysterical Italian video on "Fresh Made Pork Sausage"
- Bruce W. Hollis, PhD's & Dr. John Cannell's response to the latest research on vitamin D levels & CRP
- The effect of exercise on the genetic risk of Alzheimer's
- The best slow-cooker
- Dr. Esselstyn's 14 minute recent TED talk in Cambridge, MA
- A video about the pros & cons of nuts from Dr. John McDougall
- And whole lot more