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CHOLESTEROL CONUNDRUM SOLVED (SORT OF)


Last September I went in to see the doctor for my annual check up. In my adult life I had only undergone routine blood work once before, when as a medical resident at the University of Colorado with awesome insurance I elected to have the full battery of tests, the works. At the time (2009) I was somewhat health conscious, running and monitoring my food intake. Into my 60-hour work week I sometimes even managed to squeeze as many miles, though my weekly mileage was usually in the 30-ish range. My diet, which consisted of oatmeal with some fruit in the morning, lightly cooked vegetables with some animal protein, either in the form of egg-whites or canned tuna, for lunch, and yogurt and peanut butter for dessert with whey protein smoothies for snacks, could be called lacto-ovo-pescatarian, to give it a name. Or "almost omnivore," since my meals included every dietary staple except feathery/furry animals.

Though I have since discarded the paperwork I still remember some of my values. Total cholesterol was 199 mg/dL (reference interval is 100-199); LDL was 129 (reference interval 0-129 if you're under 40, which I was at the time). My glucose was in the 115 range. The reference for fasting glucose is 70-99 mg/dL, but I had eaten an orange just before my blood draw, so I chalked the elevated value to breaking my fast. As you can see the lipid panel (cholesterol values) was high normal which at the time was to be expected since I was consuming many foods with cholesterol and saturated fat, which studies also link to high cholesterol. And high normal is still normal, so I gave the matter little thought. Besides, I learned in my medical training not to hang my hat on lab values, since an individual's blood work can vary on any given day even at the same hospital or clinic, and marked variations sometimes exist depending on which laboratory performs the analysis.

Since the 2009 blood draw I had changed my lifestyle. Ditched animal products and alcohol, exercised more. And so as a vegan athlete when I underwent the follow up tests I expected my lipid and fasting glucose values to be normal if not exceedingly low. Because the vegan diet excludes cholesterol and is low in saturated fat, surely my cholesterol values would go down. I was anticipating values for LDL in the 70 range. Blood sugar is trickier. In place of animal protein I had taken to consuming large quantities of dried fruit, particularly dates, which are very high in sugar. Granted I customarily ate dates before and after runs, as a fuel source, but going into the test I knew that perhaps my blood sugar levels would not be much different from what they were back in 2009, that is 115 mg/dL or thereabouts. 

Sure enough my blood glucose was precisely that. 115. Okay, I'd have to cut out dates. And then I looked at my lipid panel. Total cholesterol 227 was a jump of nearly 30 points from the previous value. LDL of 147 was a an increase of almost 20 points. Mind-boggling. I could not explain how not eating any cholesterol and minimizing saturated fat could actually cause these values to leap in the wrong direction. 

The doctor told me to come back in a few months to repeat the studies. During this time I made some changes. Nothing major. As I said I cut out dates. I had sometimes been eating 20 dates a day, or 1000 calories worth of simple sugars. Not any more, no sir. In place of dates I had no choice but to increase my consumption of fat. That is if I wanted to continue working out so strenuously, because running 10 miles a day burns 1000 calories, or 20 dates, or as it became for me, some nuts (usually raw and unsalted, often mixed with a modest portion of raisins; either that or nut butter) and additional avocados. Some days I would eat 3 avocados, big ones. Hey it wasn't sugar.

"Why not eat more protein instead?" I hear you suggest. Good question. Replacing simple sugars with protein is not really an option on a whole foods, plant-based diet. Hemp protein and soy protein and other highly processed supplements don't do it for me. They upset my tummy and make my face fat, no kidding. Most vegan whole food proteins, such as beans and greens, are intimately linked with carbohydrates, which I was getting enough of. That is if they are not they are high in fat, like nuts. So nuts were the lesser of two evils, and tasty too, so I didn't mind. 

Nuts in place of dates, in other words less sugar more fat, was pretty much the only change I made, thinking that eating fewer carbohydrates would have to make my blood sugar go down. As for the high cholesterol, all I could think of was the pint of butter I had consumed over the course of one week back in August. But surely that could not have been enough saturated fat to make such a dent in my LDL. The only other theory, as the biochemists will tell you, is that eating so much sugar combined with fat - and avocado and dates were my go-to combination after a run, strange as this may seem to those who are not pregnant - causes insulin levels to rise; insulin is the "hormone of plenty," and high levels signal the body to synthesize and store fuel in the form of glycogen (long chains of sugar), triglycerides (long chains of fat), and also cholesterol. But why not just make more fat? That sugar in my diet could convince my body to synthesize cholesterol instead, de novo from dietary fats and more than is physiologically necessary, is therefore a possibility, however counter-intuitive it seems. Cholesterol is needed for the synthesis of important molecules including vitamin D and testosterone, but why my body needs so much is beyond me. In addition cholesterol is the main component of bile, which your liver makes and stores in the gallbladder. Bile is secreted in the presence of fat and helps your body absorb fat. So by eating more fat I'd need to produce more bile which could possibly cause my cholesterol levels to go up. But I didn't have any other choice really, other than simply to eat less, which sucks.

Anyway, I went back last month (February) for repeat work and found that my lab values had responded appropriately to my dietary modifications, though not to the hoped-for degree. Fasting glucose fell from 115 to 100. Total cholesterol fell from 227 to 200. LDL fell from 147 to 111. HDL, the "good cholesterol," increased from 59 to 75 since September. Here these values are, in table form:

                                                     9/15                     2/16                   reference range
glucose:                                       115                      100                         (65-99)

total cholesterol                           227                      200                        (100-199)

LDL                                             147                      111                        (0-99)

HDL                                               59                        75                        (>39)

For HDL, anything over 59 is considered cardioprotective and is a negative risk factor for heart disease, because HDL scavenges cholesterol from the blood and prevents it from clinging to your arteries.

Another word about interpreting these values. Total cholesterol is less significant than LDL. This is because total cholesterol includes both bad and good cholesterol, the formula being LDL + HDL + triglycerides/5. My triglycerides have always been below 149 mg/dL, which is normal. So those with high levels of good cholesterol (HDL) like myself could have levels of total cholesterol that are misleadingly high, and as you can see my bump in HDL of 16 points must be taken into account when interpreting a drop in total cholesterol of 27 points albeit the total value, at 200, is still slightly higher than normal. For this reason doctors focus more on the LDL or bad cholesterol when evaluating your risk for heart disease. 

Also noteworthy is the cholesterol ratio, which is simply your total cholesterol divided by your HDL cholesterol. An optimal ratio is less than 3.5-to-1. The lower the better. My ratio (200/75) is 2.67. So despite total cholesterol and LDL values that are higher than what they should be for a person my age, overall my lipid panel could be read as optimal due to high HDL, which by the way you can increase through exercise, drinking in moderation, and eating omega-3 fatty acids such as are present in flax and chia seeds.

One more thing deserves mention, and this is the view that is gaining greater acceptance in the medical community that it's not really your cholesterol values that predict your risk of heart disease: it's the level of inflammation in your body that counts. Because cholesterol does not by itself cause plaques to form in your arteries (atherosclerosis). It is the overzealous inflammatory response to LDL molecules that get stuck in blood vessels that is the real culprit. 

So how to determine your inflammatory status? Simple. Ask for a test called C-reactive protein, which is becoming more routine so you may not even have to request it.  CRP values below 1 mg/L indicate a low relative risk for future cardiovascular events. My level is 0.35, which is real low. Conclusion: I'm good. If you wish to decrease inflammation, exercise, eat fruits and vegetables, don't smoke, and avoid animal products and processed foods.

To conclude, by increasing my intake of fat I somehow lowered my cholesterol, which is itself derived from fat, confound it. And why my LDL should be anything over say 70 is another of my life's greatest mysteries. High fiber diets are proven to lower cholesterol. Fiber binds to dietary cholesterol (which is inapplicable to vegans) and also to bile (which is) so that cholesterol gets excreted rather than reabsorbed, necessitating that your liver either makes more of the stuff or makes do. And at over 100 g of fiber per day, my intake is 2.5 times the amount recommended for males. So much for the science. They don't call it the art of medicine for nothing. Abstract art, if you ask me. As in in-f@$%*ing-comprehensible.

As for lowering blood sugar even further, exercise and healthy body weight are the standard go-tos. At 5'10 and 150 lbs, my BMI is right where it should be (21.5). Also it is important that your weight not be centered around your middle. So-called visceral fat coats the organs and causes sugar and lipid levels to go up. My waist is a 29. I'll probably have to further decrease my sugar intake, not by eating less sweet juicy fruit which is high in water and fiber and therefore in glycemic index, but by minimizing vegetable juice - carrot and beet and apple juice have a lot of sugar, and without any fiber - and also (possibly) by cutting back on the herbal sweetener stevia, which though calorie-free may like other noncaloric sweeteners (sucralose, aspartame, saccharin, and the like) derange the body's glucose metabolism. The jury is still out. And I may have to ditch the dried fruit altogether. Raisins get stuck between the teeth anyway, so eliminating them can only reduce the risk of dental caries, and I so dislike the dentist. As a former flame used to say, that's killing two birds. Shows you what dietary modification can do. Because working out less, and therefore eating less of everything, just doesn't seem all that fun. But it may have to do. 

Because long bouts of physical activity drastically increase caloric needs. The person running 70 miles per week must consume at least 7000 additional calories to replenish energy stores. Seven thousand calories is what the average person eats in 3 days. The exercise buff is therefore like a pregnant person, in other words almost eating for two! And more calories require additional digestive work, not to mention more fiber than one's system can comfortably accommodate. If vegan food offers 4g of fiber per 100 calories, then eating 2500 calories provides 100g of fiber. Going on a 10 mile run and eating the 1000 additional calories would then supply an additional 40 g of fiber, which is more than the average male eats in an entire day, almost twice as much as what is recommended for females. Being pregnant indeed!

And though they have served as a band-aid for me, nuts are not the ultimate answer. I neglected to mention (because it is a sore subject, literally) that while indulging in trail mix I have had more herpes outbreaks than I normally do. Nuts are astoundingly high in the amino acid arginine, which the herpes virus uses to replicate. And the beta-oxidation of fat generates more free radicals than are produced with the breakdown of sugar or protein. Your body must neutralize free radicals with anti-oxidants (vitamins A,C,E and the mineral selenium), which with the exception of vitamin E, and selenium in Brazil nuts, nuts don't supply, unlike fruits and vegetables which are loaded.  

And nuts - which are also high in omega-6 fats, the precursors to inflammatory prostaglandins, which themselves cause airway constriction that can cause or mimic the effects of asthma, or at least make you short of breath, not exactly the endurance athlete's idea of a good time - are clearly not the answer.

So what is? As with all things, moderation is key, though I so like to exercise strenuously. But I know that when I do exceed, say, the ACSM's goal of 150 minutes of endurance exercise per week, equivalent to running about 20 7-minute miles, I do so at the risk of my own health, contrary as this may seem. Backwards world much?

This post highlights the only values you'll ever need to ensure health maintenance, and they are:

1. fasting glucose (below 100)
2. HDL/LDL ratio (below 3-1)
3. CRP (below 1) and/or ESR (<5-10 mm/hour) to monitor inflammation
4. blood pressure (110/70 or lower is optimal)
5. waist/hip ratio under 1 (ideal is .85). 

This is assuming your thyroid, liver and kidney function, as well as your vitamin D level and hematocrit (a marker for anemia, iron and B12 deficiencies) are all normal. And if they're not, and you've had routine blood work done in your recent history, you'd know it. 

So get your levels of the above 5 values within range and you can be almost positive that you will not die of the major killers, which are heart attack, cancer, diabetes, and stroke. In other words you can be pretty sure that barring unforeseeable catastrophes you'll live to flirt with 100. Whether you want to is another story.

Comments

  1. Hi,
    does this mean that the guidance you gave in the Paradigm Diet has changed? If so will you be writing an addendum to the book which will be available? Also when you said you had a 'pint of butter' in August what do you mean ? I thought you were vegan?

    ReplyDelete
  2. Hi John,

    No the advice doesn’t change. In the Paradigm Diet I never advise eating a lot of dates or other dried fruit. In fact I advise expressly to minimize. I just got into the pesky habit due to working out strenuously (sometimes running 90 miles per week while training for various events) and a little habit/convenience. In a perfect world I’d have eaten fewer dates and more sweet juicy fruit or more beans to fulfill caloric needs. But they taste so good!

    In giving them up I went to nuts because like dates they are convenient, raw, and concentrated, and it was hard to give up such a tasty treat cold turkey. In the future I will likely wean myself off nuts or enjoy just the occasional handful, which I mention doing in Paradigm, and just have more juicy fruit and beans.

    I mentioned the butter, which was a cofounder, since it was lying around in my mother's fridge and I became a “cheagan” for that week or two in August, and the pint may have been more like 8 oz. A bit of hyperbole. But other than that moment of weakness, and a can of tuna which led to a cold sore the following morning, the cheagan is proudly a vegan.

    Take home message: choose juicy over dried fruit, beans over nuts, when you eat dried fruit brush your teeth, and take care not to overdo it in the workouts (I’m closer to 35 weekly miles rather than 70, which involves a lot less food). Oh, and try not to cheat. There's your addendum. 😊

    ReplyDelete
  3. I added a few explanatory paragraphs in response to you concerns. I've pasted them here for your consideration. Thanks so much for reading.

    "Long bouts of physical activity drastically increase caloric needs. The person running 70 miles per week must consume at least 7000 additional calories to replenish energy stores. Seven thousand calories is what the average person eats in 3 days. The exercise buff is therefore like a pregnant person, in other words almost eating for two! And more calories require additional digestive work, not to mention more fiber than one's system can comfortably accommodate. If vegan food offers 4g of fiber per 100 calories, then eating 2500 calories provides 100g of fiber. Going on a 10 mile run and eating the 1000 additional calories would then supply an additional 40 g of fiber, which is more than the average male eats in an entire day, almost twice as much as what is recommended for females. Being pregnant indeed!

    "And though they have served as a band-aid for me, nuts are not the ultimate answer. I neglected to mention (because it is a sore subject, literally) that while indulging in trail mix I have had more herpes outbreaks than I normally do, and the beta-oxidation of fat generates more free radicals than are produced with the breakdown of sugar or protein. Your body must neutralize free radicals with anti-oxidants (vitamins A,C,E and the mineral selenium), which with the exception of vitamin E, and selenium in Brazil nuts, nuts don't supply, unlike fruits and vegetables which are loaded.

    "As with all things, moderation is key, though I so like to exercise strenuously. But I know that when I do, I do so at the risk of my own health, contrary as this may seem."

    ReplyDelete
  4. Thanks for the response Adam. It's easy to fall into habits of convenience. I should know, I went vegan just over a year ago and spent an age exploring all options before deciding to be more health conscious. I think your book is great, I found out about it through Robert 'Bobby' Martin (Frank Zappa's vocalist keyboard player in the 80s & 90s). I'm glad I can stick to the guidance in the book as it's really straightforward and easy to follow. Thanks again for taking the time :)

    ReplyDelete
  5. My pleasure, John. I wish you continued success. Rock on! :)

    ReplyDelete

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