Cholesterol: Fact or Fiction? What Effect Does Diet Have on Cholesterol? But the More Important Question is: "What Effect Does Diet Have on Your Cardiovascular Health?"

 

 

 

 

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

Comments

[Susan]

This is great information. And I love your postings on Facebook. Keep them coming, and thanks so much.

[tom]

I really enjoyed the guest post on cholesterol. I have several friends who follow some form of paleo/primal/WAPF diet and they routinely tell me that saturated fats and cholesterol are not only good but good for me. I really don't pay them any attention and let my results speak for themselves but it is very nice to read such an articulate and balanced response. Thanks again and love your blog.

[Willow]

I try to read all the facebook posts, but I haven't been able to keep up. Love them though.

I'm not a success story--yet. When I adopted the plant based diet, my cholesterol levels plummeted but I was still taking a statin drug. Then after 10 years of statin use, I quit taking them. My cholesterol did pop back up to nasty high levels (230) and my LDL was still slightly high also. BUT. I'm sticking with the plant based diet because the research still shows that it's my best option to avoid heart disease. And maybe as my body adjusts over the next year, I'll see the change of much lower blood cholesterol levels. I certainly look healthier (and thinner) and feel better.

[The Healthy Librarian]

@Willow--if a low-dose statin will make a difference--don't avoid it. Talk to your doc.

[Linda]

My cholesterol numbers and blood pressure numbers both elevated significantly following menopause. I took a cooking class sponsored by the CancerProject.org at about the same time. I learned shocking facts about my traditional "All American" diet and have been a vegan ever since. Overall, I feel much better for having made the change. BUT, it did not affect my cholesterol numbers at all which was a huge disappointment. So, for about six years I have been taking Lipitor and Niaspan which do the trick. Three years ago I suddenly experienced symptoms that led to a diagnosis of rheumatoid arthritis and now take methotrexate and Embrel. My frequent blood tests so far show my liver is still in good shape so that's somewhat encouraging considering the drugs that it is processing. My RA doctor in Ann Arbor, MI is reputed to be among the best BUT he advocates that meat and dairy are important to a healthy diet!! It all becomes quite frustrating. Thank you for your terrific posts, recipes, etc.--I get them on a feed; don't like facebook.

[Happy]

Not exactly a story, but a work in progress. Vegan since reading The China Study in 2005, no added oils since reading Prevent and Reverse Heart Disease in 2007. I do eat too many nuts -- but no added oils. Age 68. Blood testing six days ago for annual physical:

LDL 69.0
HDL 48
Triglyceride 70
Cholesterol 131

So far, so good.

[The Healthy Librarian]

@Happy--You're story is a victory Happy! Always happy to hear from you!

[Tristen]

I went to college (for dietetics no less!) and was taught the same lies! At that time, I also found out I had Familial Hypercholesterolemia. Which simply means I have a genetic disorder effecting my body's regulation of cholesterol manufacturing. It's stuck "on" and my numbers will always be high. I have been a vegetarian most my life and since college mostly low fat and high fiber. I was told to take statins in my 20s and told I couldn't effect my numbers much more because I was already living a "healthy" lifestyle. In Dec. 2010, I read Dr. Esselstyn's book and decided to try his food prescription for myself. I tested before and 3 months after being "plant perfect". I was amazed to have my total cholesterol about 30 points from low fat vegetarian to no oil vegan. My numbers are still high (if not on statins) but what I was told by Dr. E "What determines heart disease is not the numbers but rather knowing the food you are eating can not injure you." Even though I will never have great numbers I am confident my vessels are being well cared for by the foods I choose to eat and not to eat. Thanks for your time and blog- it has been such a wonderful resource for me on my journey!!

[Anonymous]

I am a plant-strong Registered Dietitian and an avid exerciser, especially long distance cycling. I read your blog religiously and I love it! I've learned so much from you! Thank you!

I am so disappointed with my profession (American Dietetic Assn, now known as the Academy of Nutrition & Dietetics, and the medical field in general), which continue to promote "moderation" in diet. It just doesn't work in the fight against disease.

People think I'm weird eating the way I do.

The husband of a woman I work with had a heart attack and 3 stents placed last week and they have no plans to change any dietary habits. Another guy I work with is obese and was just diagnosed with metabolic syndrome at age 43. I asked him how he felt about that and he shrugged and said, "I knew it was coming, but I don't want anyone telling me what I can and cannot eat." So frustrating.

Some people at work ask about my food and they remark on how "disciplined" I am.

It's not discipline. It's my lifestyle and I LOVE all the foods I eat! (thanks for all the great recipes and cookbook recommendations!) All that other stuff they bring in (fast food, fatty, sugar laden stuff) is not even appetizing to me.

Anyway...I wondered if you have seen these two articles? The first one made me really angry and sad at the same time. An endocrinologist disses diet and lifestyle for treatment of DM.

The second one made me happy,because it shows one of the lasting benefits of exercise as we age. Please continue to encourage physical activity to your readers!

http://www.medpagetoday.com/Endocrinology/Diabetes/30599#.TxL8tzxwTxE.gmail

http://sweatscience.com/the-incredible-unaging-triathlete/

[Ann]

Hi...I am 'the reader from New York' that originally asked the question and deeply appreciate your going the extra miles - as you always do - to clarify this point. I want to add that the one thing that practically leapt off the page at me from the statements the cardiologist made:

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.

Re the 'anti-inflammatory and pro-endothelial effect' of statins...doesn't a plant-based no-oil Esselstyn diet have that VERY effect? Along with an enviable bevy of other benefits?

[Carol]

I admit that I'm not a perfect plant-strong person, though I've been vegetarian for about 20 years, and always moving in the vegan direction. On two occasions, knowing that a blood test was coming up, I've gone to a very disciplined no-oil vegan diet for 4-6 weeks before the test. Both times, my total cholesterol dropped from about 240 to 180 in those few weeks. (The women in my family have a history of heart disease, so there may be a hereditary reason for the pretty high numbers even while vegetarian) Last time I added some extra tweaks for triglycerides, from going over your blog (cutting way down on sugar, for instance), with very encouraging results:
Total chol: 178
LDL: 92
HDL: 60
Trig: 128
ApoB: 79
So I know it works, and have no excuses, but each time, once the test is done, I relax and smile for awhile, and then Christmas comes, or traveling, or someone's birthday, and before I know it, months have gone by. But I'm working on it again.
The other interesting test was my vitamin D levels. I bought the rainbow light lemon drops, and they were so delicious that I had no trouble remembering to take them for about 3 months before the test - just one a day in the interest of thrift. After 3mo of supplementation, my Vit D blood level was 31. Again to be thrifty, but also to avoid the sugar in them, I bought some regular Vit D tablets and decided to take 2000 units a day, but somehow......it isn't quite as easy to remember when they aren't delicious (!).
Thanks again for your blog and all the great encouragement.

[The Healthy Librarian]

Carol---See, that's why I shell out for the Rainbow Lights--because I actually take them. My husband found a really good price through Amazon--but, no where as cheap as the tablets--that I never took. BTW--it's just a tiny amount of sugar.

I totally remember "cramming" for a lipid test by being "good" for a week. I guess it kind of defeated the purpose. But, I always used to do that, too. You might want to oodge that vitamin D level up a bit--31 is the lowest acceptable amount for the bone to absorb calcium.

[Confused]

I don't get it—how does Carol know what her lipid and Vitamin D levels are before her tests? Is she actually referring to a prior test much earlier for the baseline? Or does she get tested (perhaps at a location such as Walgreen's), change her diet and then get tested again "for real" a few weeks later ? I do undertand the practice of "studying" for your cholesterol test—my brother used to do it.

[Carol]

Oh, sorry - yes, that was the difference from a previous test. I've been part of a program that lets me test more often than usual because of family history. I was so encouraged because not only did the total cholesterol come down by 25%, but the triglycerides went from 240 to 128, and apoB was down about a third too. Since this was after only 4 and 6 weeks, imagine what would happen if I stuck to it all the time....! I'm working on it....

[Happy]

Receiving Vitamin D test result took a few days longer than my lipids results I gave in my earlier post. This year my Vitamin D level made it to 54. My husband and I each supplement with 6,000 IU Vitamin D3 daily -- we increased to that level early last summer. His Vitamin D level recently tested at 60. Perhaps coincidence, but neither of us has had a cold since increasing our Vitamin D intake to that level.

Still a Happy work in progress . . .

[Kate H]

Just wanted to let you know that I enjoy sitting down each evening and seeing what you have posted on Facebook. I think you are giving us more info this way and I like spreading it out over the course of the week. I found you through the NYTimes Health comments and after reading a few of your comments I became hooked. I've been plant strong since Nov. 2010 and have gotten my husband and 2 sisters onboard. It is a great feeling. Thanks so much. (ps - I just could not keep up the ten prunes a day.)

[caryn]

Terrific information, as always! The analysis was brilliant and thoughtful. Love it.

I am in a pickle. I had much better cholesterol ... Lower overall, lower LDL ... Last year before I started vegan, no oil, all whole grain eating. My MD, husband and I are baffled. Doc even tested the cholesterol more deeply for stickiness and other related things. I don't get enough aerobic exercise so I will add that and I still eat nuts and avocados.

My cholesterol is 215 now. I think it was 170 or so last year. Just to give you and idea.

Now, I have no desire to return to my former ways of eating. I can tell that I am more healthy than before and besides I love it. Things I am trying include more aerobic exercise, singing lessons for stress reduction, cutting back on nuts and ... Hmmm any ideas?