A Spoonful of Medicine Helps the Sugar Go Down

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Phil Nuttridge continues his series of articles looking at the modern take on diet and nutrition.  He explodes many of the dietary myths that have defined the latter decades of the twentieth century and left their legacy of chronic illnesses in the first decades of this century.  In this month’s article he explores the ‘cholesterol is bad’ myth and aims to make you love this clever little molecule rather than fear it.  More information can be found on Phil’s website cuttingcarbs.co.uk or by following him on Instagram:  CuttingCarbsUK

Marti the Martian loved his job.

Marti had worked in the department observing alien worlds for quite some time now and just six months ago he had been promoted to the section watching Earthlings.  This was a particularly rewarding job as humans proved to be the most intriguing of all aliens.  His most recent project had been to try and understand why so many Earthlings would choose a man called Trump to be their leader.  That project had been a been a bit disappointing as, try as they might, no conclusive answers were found.

Marti was therefore pleased to be assigned to a new project.  This time he was to look at why there are so many accidents on Britain’s main road network.  Armed with his notebook and pen (he was very old-school), Marti hovered in his flying saucer observing the motorways and trunk roads in the UK.  He saw the aftermath of many road traffic accidents on the network, sometimes involving just a few cars, sometimes involving many.  Sometimes lorries were involved, sometimes buses.  Sometimes the accidents just caused a minor disturbance in traffic flow; sometimes the roads became blocked. 

Then he started to notice a pattern, something Marti was very good at.  He noticed that in the aftermath to pretty much every accident there were ambulances.  If the accident was small there might just be one ambulance.  If the accident was rather larger there would be more.  Sometimes there would be so many ambulances that they would block the road completely causing snakes of traffic to back-up behind them, leading to road chaos.  And it was a perfect correlation: Where there was a stationary ambulance on the roads, there was an accident; when there were no ambulances, or the ambulances were moving freely, there was rarely a traffic accident.  

The more he observed, the more it confirmed this correlation.  Ambulances were bad news as far as traffic accidents were concerned.  He even refined his theory after a bit more observation by making a distinction between two sorts of ambulances: There were the “bad” ambulances, the ones that had blue flashing lights and then there were the “good” ambulances that did not.

Excited with his conclusions, Marti zoomed back home in his flying saucer and compiled his report.  Ever keen to impress his bosses he even made a Martianitarian suggestion of how his race could help the poor Earthlings:  let’s invent a ray-gun that selectively destroys “bad” ambulances and point it at the Earth.  In that way, so many road traffic accidents would be prevented that the Earthlings would be ever grateful to Martians, or so Marti believed.

So, the story of Marti and his ‘ambulance theory’ is of course analogous with a very serious message.   Let me translate the story:

• For the main roads and motorways in the story, read our blood arteries
• For the road traffic accidents, read damage to artery walls.  Therefore, a clogged road in Marti’s story =  a clogged artery, and traffic chaos = a cardiovascular event such as a heart attack or angina attack.
• For ambulance, read cholesterol and therefore, for “bad” ambulance, read “bad” cholesterol and for “good” ambulance, read “good” cholesterol.
• And finally, for Marti’s selective ray-gun, read statins.

Now re-read the story with these translations.  

Whilst this analogy is light-hearted, the story of cholesterol is not.  If you are of my age (mid fifties) you will have grown-up with the perpetual fear of dietary cholesterol.  Eggs are the enemy or so we have been told.  Eating cholesterol raises your blood cholesterol.  Blood cholesterol clogs your arteries and clogged arteries will give you a heart attack.  And then, like parents instilling fear in children with tales of the bogeyman, by sleight of hand, saturated fat gets thrown into the horror mix as well.  Eat saturated fat and that clogs your arteries too, though no one really explains quite how that fits with cholesterol.  Then it gets fudged even more, do we mean saturated fats or all fats?  Synthetic fats, created by big business and for big profit, seem exempt from this “fat is bad” story.  I grew-up being told that polyunsaturated fats in margarines were better for us than natural saturated fats.  No one told me how the synthetic forms of polyunsaturated fats are strongly linked to cancer and heart disease.  But did you also know that lard (how my generation have been told to boo-hiss this fatty poison) is actually only 40% saturated fats; 60% of lard is naturally occurring mono- and poly-unsaturated fats?  If unsaturated fats in margarine are healthful, why are they not also healthful in lard, the ones in lard having the advantage of being natural and not manmade?

There is an elephant in the room of course.  Hominids, of which Homo sapiens is just one species, have been eating fat in all its natural forms for millions of years.  For certain populations and at certain times of year, fat has been almost the entirety of our diets.  And yet heart disease is a new phenomenon and has only been a clinically identified condition for less than a hundred years.  Can eating something we have been eating for millions of years, suddenly (in evolutionary timescales, the last one hundred years is just the blink of an eye) be causing heart attacks?  In that same one hundred years we have been eating way more sugar, way more grains, way more refined carbohydrates and way way more of the artificial fats. And yet we exonerate all of those additions to our diet as the cause of heart disease and instead blame naturally occurring intrinsic fats and cholesterol which we have always eaten.

Let me begin the rehabilitation of cholesterol.  If you really believe that cholesterol is bad for us, you are in for quite a shock when you see this list of cholesterol’s virtues:

1. Cholesterol is essential for the building and maintenance of the walls of all cells in our body.  Every cell membrane is made from a mixture of cholesterol, fat and protein and its integrity and function is essential for controlling what enters and leaves the cell and so, for all aspects of cellular communication.  Without cholesterol you will die.
2. Cholesterol is an essential precursor for all steroid hormones in the body.  Cholesterol is therefore vital for the hormones that control (for example) blood sugar levels, the stress response, mineral balance, blood pressure and the reproductive system.  Without cholesterol you will die.
3. Cholesterol assists the body with fat digestion.  Bile salts are synthesised from cholesterol and are essential for the digestion and therefore absorption of fats and the fat soluble vitamins (A, D, E and K).  Rather cleverly, Nature knows this and virtually every natural source of fat includes cholesterol to aid its digestion. Without cholesterol you will die.
4. Cholesterol is a key component of the fatty myelin sheath on nerve cells, required of their efficient function.  A quarter of your body’s cholesterol is unsurprisingly therefore found in your brain.  Cholesterol is consequently essential for movement, sensation, thinking, learning and memory.  Without cholesterol you will die.
5. Cholesterol is essential for the production of Vitamin D in the body.  Sunlight hitting cholesterol in the skin cell membranes, turns the cholesterol into Vitamin D.  This vitamin is proving to be one of the most important of all Vitamins, so much so that in some clinical circles it is now considered more of a hormone than a vitamin.  Vitamin D controls immunity, calcium and phosphorous metabolism, bone health and mental health.  Without cholesterol you will die.

Without cholesterol you will die.  

Our evolved bodies know all this, and probably more that we do not yet know.  We have a very sophisticated metabolism that controls the level of cholesterol in our blood.  If you eat less, you liver produces more; if you eat more your liver produces less just to keep your serum levels of cholesterol at optimal levels.  So cutting eggs (and other sources of cholesterol) out of your diet will not impact your serum levels of cholesterol as the liver will manage the situation.  Statin medications interrupt the enzymes in the liver that perform this control and so have to be bad news.  Though I would caution that those very few of the population with congenital hypercholesterolemia who have an impaired cholesterol regulation mechanism may have to resort to medication to manage this genetic problem.  But this condition is very rare.

The next myth about cholesterol is that there are not “good” and “bad” forms. There is only one form of cholesterol and as I have shown above it is always good.  There are however multiple forms in which cholesterol is transported around the body.  The ‘taxis’ cholesterol uses are know as lipoproteins and they come in quite a number of forms.  The two you may have heard of are LDL and HDL – low density lipoproteins and high density lipoproteins.   It is a commonly held belief that HDLs are the “good” cholesterol and LDLs are the “bad”.  Yes, a high concentration of HDLs in your blood IS correlated with good health outcomes.  The evidence that high levels of LDL are bad for you is very circumspect.  To use the statistical jargon, the correlation between raised serum levels of LDL and cardiovascular outcomes is very low and contradictory from different studies; there are other blood measures that have stronger correlations with heart disease and I will come to those later.  We do not hear a great deal about the virtues of raising the levels of HDL to improve health outcomes because there is not a drug to do that job for us.  Diet is the best way.  Eat lots of natural intrinsic fats and cut the carbohydrates in your diet and your HDLs will stay protectively high.

In addition to HDLs and LDLs, there are more forms of cholesterol ‘taxi’ that we hear less about.  I would cynically argue the main reason we hear less of these variants is that Big Pharma does not have medication-based ways of controlling the levels of these other forms of lipoprotein.  The one I shall major on here is VLDL – very low density lipoproteins.

If you have been able to persuade your GP to carry out a full lipid panel (not just the standard single measure cholesterol test which is in itself meaningless) then you will have had this measured.  It is usually referenced as ‘Triglycerides’ and this one IS correlated with heart disease outcomes.  But here’s the thing:  Do you know where triglycerides come from?  Excess carbohydrates.  Once your have replaced all your glycogen stores (the form of carbohydrate we store in the liver and muscles) from digested carbohydrates, then the liver will convert any excess sugars to triglycerides and put them in VLDLs to transport around the body ready for fat storage.  Yes, the dietary villain I keep telling you about is the root cause of the ‘cholesterol’ measure that is correlated with cardiovascular illness: Carbohydrates.

Let me quickly review some of the prominent evidence that the ‘cholesterol is bad’ story is wrong.

1. Women.  Yes, half the population of humans bely the idea that total cholesterol is bad for you.  Females have on average higher levels of total serum cholesterol than males and yet have significantly lower incidence of cardiovascular disease.  This fundamentally contradicts the hypothesis that higher cholesterol equals higher risk of heart attacks.
2. The Framingham study, started in 1948 is the longest ongoing study of health outcomes.  Based in the town in Massachusetts, the study is following the lives of over 5,000 participants and their subsequent generations (the study is now on the fourth generation inhabitants) looking at health outcomes against lifestyle factors.  This study shows that people who eat the most cholesterol and eat the most saturated fat, weigh the least and have the best cardiovascular outcomes.  Furthermore, the observational data shows that lowering of blood cholesterol levels over the age of 50, is correlated with WORSENED health outcomes.
3. The Women’s Health Initiative Dietary Modification Trial (WHIDMT).  Whereas Framingham is the longest duration observation study, the WHIDMT is the most ambitious intervention study to date.  This study took 49,000 post menopausal women and divided them into two groups:  One group was given advice, coaching and encouragement to follow a low fat diet; the other control group received no support or coaching in dietary change.  The women were then followed over a seven year period and their health outcomes examined.  The women in the intervention group (low fat diet) had no measurable improvement in health outcomes than the control group despite eating significantly less fat.  In fact, those women in the low fat diet group who had heart disease at the start of the trial, had WORSENED health outcomes by the end compared to similar women in the control group.  Furthermore, the study showed that those who had type II diabetes at the start of the trial were 39 percent more likely to develop heart disease even when treated with statins.
4. The Los Angeles Cardiac Admission study looked at the blood lipid results of 136,000 patients admitted to hospital with a coronary heart event.  This data showed that those admitted with heart attacks had lower than population average levels of total blood cholesterol and lower than population averages of LDL carriers.  If the ‘cholesterol is bad’ hypothesis were true, then you would expect patients admitted with heart events to have the highest blood cholesterol and LDL levels but this study conclusively showed they had the lowest.
5. A meta study collating data from 19 individual studies of patients over 60 years old, showed that of the combined 68,000 patients in these studies, those with high levels of LDL lived as long and in many of the studies longer, than those patients with lower levels of LDL.

Unlike the studies you hear about claiming cholesterol is bad and statins are good, all of the above studies are large scale studies and mostly studies observing patients over long periods of time.  Unlike the majority of studies supporting the ‘cholesterol is bad’ hypothesis, these studies are not funded by pharmaceutical companies. 

So, if cholesterol is not the villain in heart disease, how did it get the bad rap?  The ‘cholesterol is bad’ story started in the middle of twentieth century when there was an urgency to find a cause and hence solution, to the then rising tide of cardiovascular disease.  The early studies of arterial plaques showed that cholesterol was indeed present in these accumulations on the walls of arteries.  And because the clogged artery theory of cardiac disease assumes that it is the detaching of these plaques from the artery walls that causes the heart attacks, the eagerness to solve heart disease meant that cholesterol got the blame.  Because the studies showed that cholesterol was in the plaques they concluded that cholesterol causes heart attacks; they confused correlation with causation. Remember Marti and his ambulances – they were present in the road traffic accidents but that does not mean ambulances caused the accidents.  In the same way, just because cholesterol was at the crime scene did not mean it was guilty.  But, with the creation of statin drugs that are able to lower cholesterol levels it was game, set and match against cholesterol.  The ‘cholesterol is bad’ paradigm was born in the climate of eagerness for a solution.  Mortality from cardiovascular disease has indeed reduced since this time but most (if not all) of this decline has been due to the reduced levels of smoking in the population and better and earlier detection techniques rather than dietary or pharmaceutical intervention.

Now statins are an industry in their own right and estimated to be worth an excess of $35 billion a year to pharmaceutical companies.  A lot of financial interest is therefore vested with propagating the cholesterol paradigm, despite significant and robust evidence from studies casting significant doubt on the original ‘cholesterol is bad’ hypothesis.  

A bit conspiratorial?  Well yes, but do consider that the health profession once deemed smoking safe:  A survey in 1961 (only a little before my time) showed that sixty per cent of GPs thought smoking was safe and 41 per cent of GPs actually smoked.  There were studies, funded by tobacco companies, that showed smoking was safe and even conferred health benefits. With fifty years of hindsight we know this is ludicrous; maybe someone writing about the history of statins in 2070 might conclude the same.

Let me conclude with another piece of the cholesterol jigsaw.  Remember how it was found that cholesterol was always present in arterial plaques, but that this correlation got confused with being the cause of heart attacks?  One of the more recently understood functions of cholesterol that I did not list earlier is repair of damage to arterial walls.  Yes, it is truly like one of Marti’s ambulances!  So if we want to reduce the incidence of heart disease we need to reduce the number of instances of damage to artery walls and NOT reduce the number of cholesterol molecules that are needed to repair them once damage has occurred.  Just like we do not want to reduce the number of ambulances on our roads, we instead need to reduce the number of road traffic accidents.  Ambulances are needed just as cholesterol is needed.

And the root cause of damage to artery walls?  Inflammation.  And the cause of systemic inflammation?  Whilst there are many causes, chief amongst them are excess levels of insulin associated with insulin resistance.  You may remember I described this condition in my earlier article entitled ‘A sweet carb named desire’ and how this was linked to obesity, type II diabetes and many other conditions.  Well we can now put cardiovascular disease on this list and yes, eating too much sugar, one of the long-term triggers for insulin resistance, is the key dietary villain.  

So if you are taking medication for any of the chronic non-communicable diseases of the twenty first century, chances are all you are doing is taking medication to overcome the effects of excess sugar and refined carbohydrate in your diet.  Mary Poppins in her song got it nearly right but just the wrong way round.  She should have been singing ‘a spoonful of medicine helps the sugar go down’.

In my next article I will look at the scary world of dietary studies.  Open any newspaper and there will be a headline starting:  “Study shows……..” and then some food substance we had previously been told is good for us is now bad for us or another that was bad for us is now good for us.  And then next week it is all switched around.  In “10 out of 8 Cats Probably Don’t Care”  I will look at how all is not as it seems in dietary research.