Monday, December 9, 2013

Cholesterol – Is it Bad or Good?

Cholesterol – Is it Bad or Good?
That is the question that is being raised by many.  Cholesterol, is it good or bad?  The short answer is, yes.  However, the answer is buried in the details of a rather complex formula that I will attempt to discuss.  While current mainstream medical thought states that high cholesterol is bad and causes heart disease, further research and thinking may reveal that low fat, high carb diets designed to lower cholesterol with the help of statins may actually be causing increase levels of heart disease and causing a plethora of health issues in America today.
While I am not a doctor and do NOT recommend that anyone make any dietary or medical changes without conducting their own research and consulting with their doctor,  information I have learned through a vast self-study and inquiry over the past few weeks has me questioning my approach to improving my heart and general health.
Last week I took a stress test to  learn if there were any outwardly signs of heart disease and not only was the test clean, I had managed to put up one of the best tests the exercise physiologists had seen.  Feeling good about these test results and that I do not have outward signs of the onset of heart disease, I wanted to further study the effects cholesterol, exercise, diet and most importantly statins (atorvastatin) have on “preventing” heart disease and on health in general.
As most know, I have mostly abandoned dairy and meat in favor of a plant based diet. While I do not follow a strict plant based diet 100% of the time, I do stick to this form of eating 90-95% of the time.  I also exercise 15-25 hours a week, depending on where I am in the training cycle for major triathlons or marathons. So far so good.
While on a recent business trip I picked up a copy of the book “Sugar, Salt and Fat, How the Food Giants Got Us Hooked” by Michael Moss and I was intrigued and shocked at what Moss brings to light in his book.  In summary he showcases just how much sugar, salt and fat the food giants include in processed food.  While May and I do not eat a lot of processed foods, I discovered that I had much more sugar in my diet than I realized and was consuming more bad carbs such as white rice, pasta and white potatoes than I realized. These are killers of HDL (good cholesterol) and raise the ever dangerous triglycerides.

During a recent health screening benefit at work, I was able to have a cholesterol work up done and at the time I felt good about the results.  While not perfect, most indicators were favorable. Having had time to further study cholesterol and heart disease I became concerned about my results and if they truly were indications of health or early warnings that further changes may need to be made in my diet.  My total Cholesterol was 160, HDL 36, LDL 92, Triglycerides 202 and blood glucose 88. While my HLD (good cholesterol) was a bit low and my triglycerides a bit high, the overall test results were “good” and based on mainstream medical thinking they are in line with heart health. A non-smoker, avid exerciser and a “heart healthy” diet, all is well, or is it?  Let’s take a closer look at cholesterol, statins and diet as they relate to heart disease. Bear with me as this is a rather in-depth analysis and will take a while to explain.
I love to study and learn new things, in particular things that are exercise, endurance sports, diet and health related.  I have recently discovered Dr. Steve Gangemi, better known to many as the “Sock Doc.”  He resides and practices in Chapel Hill, NC and practices holistic health, with an aim for preventing health issues while also identifying and fixing the causes of medical issues rather than treating the symptoms.  With many IRONMAN triathlon finishes to his credit, he understands sports and endurance fitness and concentrates on endurance athletes and athletes in general but works with the general public as well.  His web sites are and
Wanting to understand the “why” behind training, health, processes, etc., I am attracted to Dr. Gangemi’ s thinking and processes for preventing and healing injuries and improving health.  Preventing issues before they happen resonates with me so I was intrigued when I read his article titled “Elevate Your Cholesterol Profile, Elevate Your Health.”
While mainstream medical thought is that lower cholesterol at all costs is better, Dr. Gangemi challenges this reasoning and the role cholesterol plays in the development and proliferation of heart disease. Cardiovascular disease is caused by a wide range of nutritional, lifestyle and environmental factors (diet, exercise and processed foods) that result in inflammation that gets out of control. According to Gangemi, genetics most likely play some factor, but minimal compared to the rest. The genetic link is typically a cop-out when someone doesn’t take control of their own health. Toxins, infections, excessive stress, lack of proper exercise and diet are far more damaging to the heart than high total cholesterol.

Gangemi does not profess that high cholesterol is okay, but he does stress that lower cholesterol is not necessarily better. Cholesterol just doesn’t shift to a dangerous level without other contributing factors. A poor diet and overall health lead to unhealthy cholesterol levels whether that’s low, high, or imbalanced.
Gangemi explains that low cholesterol is often much more dangerous than high cholesterol even though we’re led to believe that cholesterol is evil. A cholesterol level below 160 mg/dl is said to increase one’s risk of many cancers, stroke, neurological problems such as memory loss and dementia, and many other health problems ranging from digestive to hormonal. He points out the components that make up cholesterol.
Some notable cholesterol functions:
It acts as a precursor to vitamin D – low cholesterol means it will be more difficult to absorb this vitamin necessary for a healthy immune system, bones, and DNA.
It is the precursor to all steroid hormones such as glucocorticoids which control blood sugar, mineralocorticoids which regulate electrolyte balance and blood pressure, and sex hormones such as progesterone, estrogen, and testosterone.
It is used to synthesize bile acids in the liver, which are important for the digestion of fats. These bile salts are then stored in the gallbladder.
Cholesterol is found in every cell of your body and is a necessary component of a healthy brain that needs to store and recall memory, process ideas, and function at its highest level.
Cholesterol is made up of HDL, LDL and VIDL which are basically triglycerides.  HLD, or better known as “good” cholesterol remove cholesterol from tissue where LDL or commonly known as “bad” cholesterol tend to deposit cholesterol in to tissues, thus their rap for being bad cholesterol.
Triglycerides, in my opinion, are the catalyst for the damage bad cholesterol can do to the cardiovascular system. Triglycerides are the main transporters of dietary fat in the bloodstream.  This includes excess fat that that results from excess carbohydrates in one’s diet.  Research has shown that a diet consisting of 60% carbohydrates (considered a heart healthy diet) can increase triglyceride levels as much as heavy alcohol consumption (two drinks per day) can.  Simple sugars are major culprits in elevating triglyceride levels.
Your body produces cholesterol and is a necessary component for a healthy body.  Cholesterol plays a role in fighting inflammation and also is a major lien of defense when your immune system comes under attack. Lowering your cholesterol can thus weaken your immune system and delay repair of injuries and muscle damage.
 Gangemi explains that all cholesterol particles can be either large or small. Ideally you’d like to have more large, buoyant HDLs and LDLs than small, and more small VLDLs/triglycerides than large. These can be measured through a more thorough lipid analysis that specifically measures the size and volume of HDL, LDL and VIDL particles.
One sign that your LDLs are most likely large (good) rather than small (bad) is your HDL to triglyceride ratio. If your HDLs are at least one-half of your triglycerides, then you most likely have large LDLs. So for example, if your HDLs are 40 and your triglycerides are over 80 that would be concerning where and HDL of 120 and triglycerides of 60 would indicate large HDL particles and small VIDL particles which is what you are striving for.
Gangemi also provides insights on other cholesterol ratios.  In his opinion, one should shoot for total cholesterol to HDL ratio of 3:1 or lower.  If your total cholesterol is 180 and your HDL is 60 that would be considered good.
Now on to LDL which is known as the bad boy of cholesterol. Gangemi explains that the LDL upper limit was dropped several years ago by most labs from 138 to 100. So now a LDL of say 125 is considered high, regardless of whether they are the small or large LDLs.
Interestingly, around the same time this happened, the pharmaceutical industry was trying to get the upper limit of total cholesterol lowered from 200 to 190. That way, if your cholesterol level was 195, your doctor would recommend a statin medication “for your health.” This never happened, but the LDL was soon lowered – a whopping 38 points. Now a lipid panel of 190 total cholesterol, 65 HDL, 105 LDL, and 100 triglycerides, (a triglyceride makes up 1/5 of the total cholesterol, so 100 = 20 of the total points), which is excellent, is flagged as having a high LDL.
While LDL is considered the bad cholesterol as it in the cholesterol that attaches to tissues (heart and artery tissue), Gangemi explains what it is about LDL cholesterol that makes it harmful.  It is the oxidized LDLs rather than LDLs per se that contributes to atherosclerosis and “cholesterol problems.” Free radicals, unhealthy fats, and a high carbohydrate diet cause the oxidation of the LDL particles.
Paul Jaminet, Ph.D. further explains LDL (low-density lipoproteins).  LDL particles serve as your body’s scouts or sentinels, detecting foreign threats like germs.  The LDL particle protein is very fragile and very easily oxidized.  When it comes in contact with bacterial cell wall components, it quickly becomes oxidized LDL, which doesn’t get taken up by cells that are looking to take in fats.  Instead, oxidized LDL gets take up by the white blood cells, and an appropriate immune response is mounted against the microbe that oxidized the LDL lipoprotein.  That’s the reason oxidized LDL are associated with a lot of health problems.  Its means you have a lot of “foreign” things that should not be inside you stimulating your immune system.
Gangemi goes on to explain more about oxidation of LDL particles. Free radical damage is often the result of lack of antioxidants in the body, such as vitamins A, C, and E but perhaps more importantly are all the healthy antioxidants found in fruits, vegetables, and herbs. Vitamin D is also a very important antioxidant – and one that won’t be well utilized by a low cholesterol body. Coenzyme Q10 is a very an important antioxidant needed by the heart and for the body to make energy. Statins (cholesterol meds) block CoQ10 from being made naturally in the body, therefore increasing free radical damage and further oxidizing LDLs. This is dangerous. The more stress one is under – physical, nutritional, and emotional – the more free radical damage your body will succumb to.  (Exercising and statin use may be more harmful than helpful).The more oxidized the LDL particles become (and the smaller the LDL particles) the more damage they do and smaller, denser LDL particles oxidize more easily than large particles.
Unhealthy fats mean partially hydrogenated “trans” fats as well as all polyunsaturated vegetable oils – corn, soy, sunflower, safflower, peanut, cottonseed, and yes definitely canola. The main reason for these oils being considered unsafe is the highly processed nature that provides long shelf life and high smoke points.
Statins – Magic, Mystery or Meddling
There are many different views on statins and their validity for “reducing chances of heart disease and death” in healthy people and in those that have already had cardiac issues. Dr. Gangemi explains what statins are and how they function.
Statins are known as HMG-CoA reductase inhibitors – they stop the synthesis of a compound called mevalonate from being formed. Mevalonate is the precursor of cholesterol, but also the precursor of squalene and coenzyme Q10 (ubiquinone), as previously mentioned.
Statins, other than blocking how cholesterol and other compounds are made, are touted as beneficial as some studies show they greatly increase the amount of nitric oxide made by the blood vessel lining which results in stroke reduction and its residual neurological effects. Some also say that statins protect against stroke by increasing the body’s ability to dissolve blood clots independently of both nitric oxide and cholesterol. Of course, as mentioned previously, you can significantly lower your risk of stroke by limiting your number of oxidized LDLs. Additionally, nitric oxide is made naturally in high amounts in healthy individuals with adequate protein intake (via the amino acid arginine) and proper cofactors (primarily manganese and vitamin B6).
According to Gangemi, high cholesterol is not the primary cause of heart disease and statins don’t decrease this risk for most people. Statins do however impair vitamin D metabolism and CoQ10 production (needed for energy production) as previously mentioned, as well as squalene production.

Squalene accumulates at the greatest concentrations in the skin, where it has a vital role as a free radical scavenger, preventing the harmful effects of the degeneration of fats. Adequate concentrations of squalene in the skin prevent oxidative damage from ultraviolet light. Squalene is also a substance that protects people from cancer. You may have heard of claims that “sharks don’t get cancer.” This is because squalene is super high in shark liver oil so you should naturally keep your squalene levels high.
That is a LOT of information to digest but in summary it appears that diets high in saturated fats and cholesterol don’t necessarily lead to heart disease. Remember triglycerides that are transporters of LDL and fats in the blood?  The higher your triglyceride number the more LDL fats will likely be elevated and if the LDL particles are small and dense the more easily they oxidize. So what drives up cholesterol?  According to Dr. Gangemi it’s the high carbohydrate diets (white flour, white rice, pasta, sugar, high fructose corn syrup and an overabundance of any grains) and so-called “heart healthy” vegetable oils (corn, soy, canola, safflower, peanut, etc.) that are linked to heart disease, cancer and most all diseases. A diet high in carbohydrates and inflammatory oils increase LDLs and oxidize them – and that can cause atherosclerosis.
Now that we know what bad cholesterol is, how it affects the body and what produces oxidized LDL particles and drives up triglyceride levels let’s look at some ways to establish and regulate a healthy cholesterol level for you.
According to Dr. Gangemi, most doctors don’t exercise or eat well and they sure don’t how to prescribe it so they fall back on the “diet and exercise alone aren’t enough” motto and recommend a statin. Proper exercise and a healthy diet can do wonders for your health and your cholesterol. That doesn’t mean you cut out all the fat from your diet and get up from your desk a few times a day to walk to the water cooler.

Dr. Gangemi offers some recommendations with the concept that maintaining heart health is about keeping inflammation at bay.
Supporting Dr. Gangemi’ s view on inflammation, Gary Taubes, science author with degrees from Harvard, Stanford and Columbia Universities, concurs that a major culprit in heart disease is inflammation.  He states that inflammation is caused when we expose our bodies to toxins or foods the human body wasn’t designed to process. These foods, however, are not the saturated fats in butter, meat and cheese-the things we have been taught to avoid.  They are in the foods marketed as heart healthy such as processed oils and processed foods.

(Authors note – While many will say our ancestors ate meat and dairy and survived, it’s important to note that the meat and dairy they consumed was MUCH different than what is found on the supermarket shelves today.  They meat and dairy they consumed was free of hormones, antibiotics and was grass fed and extremely lean. If you are going to consume meat and dairy, look for organic, grass feed meat and dairy that is free from hormones and antibiotics)
Remove all refined sugar (that includes juice) and grains from your diet. Triglyceride levels quickly drop with a low carb diet. Alcohol can also drive up triglycerides.
Exercise! Aerobic exercise is a great way to start especially if you’re already on a statin (or any medication for that matter). Strength training may be beneficial for you too.  It may be advised for you to have a stress test before engaging in any physical activity.
Eat a lot of organic vegetables – the more the better. Sorry, corn and potatoes are not veggies and due to the high starch level act more like carbohydrates and drive up triglycerides.
Keep the fruit to 1-2 servings a day; more only if you exercise intensely or for a long duration.
Eggs don’t raise cholesterol. Actually, they most likely will lower it. Make sure they’re pasture raised. Avocados, coconut milk & coconut oil are also healthy fats.  (Gangemi also recommends butter and milk but that is an individual preference and will depend on each person’s individual cholesterol profile and composition. Look for organic milk that is free of hormones and antibiotics and grass fed if possible)
Rid your diet of all the trans fats and polyunsaturated vegetable oils. In addition to exercise this may be the biggest, quick hit improvement you can make.
Consider a fish oil supplements
If currently taking a statin, take a CoQ10 supplement.  CoQ10 prevents atherosclerosis by reducing the accumulation of oxidized fats (remember the oxidization of small, dense LDL particles) in blood vessels. It also can lower high blood pressure, regulate the rhythm of your heart, and improve chest pain and exercise toleration if you have angina. (Some research shows that statins negatively impact aerobic gains from exercise, can cause muscle pain, delay the injury recovery process and negatively impact memory and cognitive function)  You can get CoQ10 naturally from red meat (grass fed), but it’s tough to eat enough. You’ll lose more CoQ10 over the age of 40 and with exercise too so if you take a statin then you’ll quickly become depleted. Dr. Gangemi says a general recommendation is 200mg a day but you need to consult with your doctor before stopping, changing or adding any new medications or supplements.
Other resources to check out that support Dr. Gangemi’ s views on healthy cholesterol levels, statins and the real causes of heart disease included:
The Statin Damage Crisis
Dr. Duane Graveline M.D., Dr. Malcolm Kendrick M., Malcolm

Ignore the awkward! How the cholesterol myths are kept alive
Uffe Ravnskov

Cholesterol Clarity: What The HDL Is Wrong With My Numbers?
Jimmy Moore, Eric C. Westman

Grain Brain: The Surprising Truth about Wheat, Carbs, and Sugar--Your Brain's Silent Killers
David Perlmutter, Kristin Loberg

If you are still with me that is a LOT of information to digest but information that makes a lot of sense and with new science, it’s worth talking about and studying.  When Pfizer created Lipitor it generated over $11 billion in revenue from this one drug and still brings in $4 billion a year on Lipitor now that it has lost its patent. This pays for a lot of research that can tell the story they want told and can go a long way to persuading the medical community that “all is well.”  I not saying you should stop taking your statin but you should arm yourself with as much information as possible and use this information with talking with your doctor about what is best for your health.
The Vokaty Chronicles
If you recall, Dr. Gangemi says one should strive for HDL to be twice your Triglyceride level and your total cholesterol to HDL should be 3:1. Based on the values of my most recent cholesterol screening at work, my HD is 17% of my triglycerides which is not good and my total cholesterol to HDL is 4.6 to 1 which is also outside the recommended level.
While I had a cursory understanding of diet, cholesterol and the effect of statins on the body before this research, my desire to research further has stemmed from a few issues concerning fatigue, a nagging knee sprain and lack of aerobic improvement during workouts.
Some of this fatigue and slow healing from injuries may be from lower than necessary protein levels.  As an endurance athlete you need between .8 and 1 gram of protein per pound of body weight. For me that is between 100 and 125 grams of protein per day, possibly more with an injury.  With my current plant based diet, I have been lax in calculating my protein intake and have likely been well below the necessary levels.  I will begin to track protein levels daily.
Armed with new information and a quest to be healthy I am going to experiment with some changes in diet and medication to see if I can improve my overall cholesterol levels, my heart and general health and my athletic performance.  I will provide updates weekly updates beginning Monday, December 2 on my progress here at “How Bad Do You Want It.” 
DISCLAIMER: I am not a doctor and you should NOT make any changes to your medication, diet or activity level without first consulting your doctor.  I do recommend conducting research yourself and prepare for the visit with your doctor with questions and information you deem important.  If you want to or are into endurance sports, strength training, etc. be sure your doctor is familiar with your sport and understands the demands, requirements, etc.
Plan of Action:
Visit my doctor and get a new blood panel taken during a fasting state (the results above were not taken in a fasting state and likely lead to elevated triglyceride levels.
Blood Work Request:
Lipid Pane - Total Cholesterol, HDL, LDL (total number and particle size) VIDL (triglycerides and particle size)
Thyroid (TSH, free T3, free T4, TPO antibody, TG antibody)
Testosterone (free and PSA)
Vitamin D (25 OH D)
Vitamin B6, A, E and C levels
Inflammation markers (hs-CRP = high sensitivity C-reactive Protein)
I stated on 40 mg of Lipitor when I was NOT exercising or eating a “better” diet and once my panel results come back, will ask to go off Lipitor for 90-120 days to see what effects diet and exercise have on my cholesterol. With that information I will then determine if I want to continue statin use.
Target 100-125 grams of protein per day
Discontinue use of any oils with the exception of Extra Virgin Olive Oil and Coconut Oil or grass fed, organic butter in moderation.
Add more healthy fats (EVOO, Coconut Oil, Coconut Milk, Low Fat Cottage Cheese, avocados, nuts, seeds) to my diet. I will still limit dairy intake due to the health and cancer concerns of the protein casein found in daily.
Add back organic, farm raised eggs to my diet – no more than one a day
Add back organic, lean protein on occasion in the form of white chicken or turkey meat, grass fed organic beef and pork along with cold water fish that is wild caught so it will have consumed its natural diet and not grain fed.
Coconut and Almond milk– Unsweetened
Eliminate refined sugar and high fructose corn syrup
Cut back dramatically on carbs, especially refined carbs and add in more vegetables with a focus on dark, green vegetables
Limit alcohol consumption to weekends
Add in more dark chocolate – 85%+ cacao – YUM (dipped in Mays homemade, sugar free cayenne peanut butter is hard to resist)
Lower salt consumption
Add 20 mg of CoQ10 supplement daily
Consume more homemade peanut butter (May’s peanut butter is totally awesome) free of sugar and limited addition of EVOO as needed.
Add more Quinoa to our diet
Continue strenuous exercise in my training for IRONMAN Coeur D’ Alene and IRONMAN 70.3 in Raleigh in June and REV3 Knoxville in May.
Desired Outcomes and Goals:
Triglyceride level half that of HDL
Total cholesterol to HDL ratio of 3:1 or lower
LDL 130 or lower with large particle size and large particle size for HDL
Reduce inflammation
Increase energy
Reduce injuries and increase recovery time
Thanks for letting me share my thoughts, concerns, ideas and plans with you. Although I feel good, your health is nothing you should ever take for granted and the best medicine is preventative, not treating symptoms after an issue arises.  I am always looking for continuous improvement and I am excited to begin this journey and have you join me. 

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