THE SINGULAR FOCUS on treating cholesterol as a means to prevent heart attacks is leading to the deaths of millions of people because the real underlying cause of the majority of heart disease is not being diagnosed or treated by most physicians. For example, I recently saw a patient named Jim who had "normal" cholesterol levels yet was taking the most powerful statin on the market, Crestor. Despite this aggressive pharmaceutical treatment, this man was headed for a serious heart attack. Jim's doctors had missed his real disease risks by focusing on and treating his cholesterol levels. All the while they were ignoring the most important condition that put him at dramatically higher risk of heart attacks, diabetes, cancer, and dementia. In a moment I will explain what this condition is and what you can do about it.
This craze for treating cholesterol has lead to an onslaught of pharmaceuticals designed to "lower cholesterol." Statins are now the number one selling class of drugs in the nation and new cholesterol medications are produced every day. The latest in a new class of "super" cholesterol drugs, CETP inhibitors, now in the drug approval pipeline from Merck (anacetrapib) burst into the news recently with exclamations from typically restrained scientists. Data on this new drug was recently published in the New England Journal of Medicine and presented at the American Heart Association conference in Chicago.
The study found a 39.8 percent reduction in LDL (or bad cholesterol) and a 138 percent increase in HDL or good cholesterol.(i) Sure, the medications lowered cholesterol. However, the study was not large enough or long enough to answer the most important question: Did the drug results in fewer heart attacks and deaths. Despite this glaring omission, the scientists reporting on these results used words such as "spectacular", "giddy", "enormous", "most excited in decades" to describe their enthusiasm over the medication. Of course, the researchers (as I described in a recent post "Dangerous Spin Doctors") were on the payroll of Merck who funded the study.
Metabolic syndrome is the leading cause of heart disease, diabetes, and a variety of other chronic illnesses in this country.
Why Lowering Cholesterol May Not Lower the Risk of Death
Unfortunately, these scientists seemed to have short-term memory loss. Just three short years ago in 2007, another new "wonder" drug from Pfizer (torcetrapib) which worked on the same mechanism that anacetrapib does, was found to dramatically lower LDL and raise HDL cholesterol, just like this new drug from Merck. There was only one small problem-in those taking the drug, deaths from heart attacks increased 25 percent, deaths from heart disease increased 40 percent and overall deaths increased 200 percent.(ii) After spending $800 million in development Pfizer had to walk away from the drug. Oops. How can a drug that does all the right things (dramatically lowering bad cholesterol and raise good cholesterol) actually cause MORE heart disease and deaths?
The answer is simple. Drugs don't treat the underlying causes of chronic illness. It is not our genes which haven't changed much in 20,000 years, although they may predispose us to environmental and lifestyle triggers of illness. The causes of chronic disease are rooted in what we eat, how much we move, how we face stress, how connected we are to our communities and toxic chemicals and metals in our environment.
A wry editorial in the New England Journal of Medicine many years ago remarked that doctors should use new drugs as soon as they come on the market before side effects develop. Perhaps that's what the authors of this study are proposing we do with anacetrapib.
At best this new "super cholesterol" drug by will lower cholesterol numbers without killing too many people while increasing health care costs by billions of dollars as millions of new prescriptions are written for this new "super cholesterol drug." Worse it may end up in the same garbage dump Pfizer's drug from 3 years ago did. Even worse scenarios exist … and the reason is startling simple …
These drugs do not address the fundamental underlying cause of heart disease. Heart disease is not a Lipitor or Crestor or even an "anacetrapib" deficiency. It is a complex end result of multiple factors driven by our diet, fitness level, stress and other lifestyle factors such as smoking, social connections, and, increasingly, environmental toxins. Taking a pill won't fix these problems that push our biology steadily along the trajectory of disease. The idea of putting statins at the check out counter of MacDonald's is the epitome of reductionist thinking. The problem isn't cholesterol-it's all the stuff we are putting our mouths!
Jim, my patient is a perfect example of how doctors treat the symptoms, not the cause of disease. As I have written about in a previous blog, most doctors focus on the wrong target for preventing and treating heart disease. Abnormal cholesterol levels are just a downstream problem that is mostly a result of "diabesity" or the continuum of blood sugar and insulin imbalances that range from pre-diabetes to full-blown end stage diabetes. Taking a statin or a CETP inhibitor cannot reverse this change in our biology. We cannot use a drug to correct what happens to our biology because of a high sugar and refined flour, low fiber, processed diet, a sedentary lifestyle, excessive stress, lack of sleep or the harmful effects of pollution.
Let's take a closer look at Jim. On 10 mg of Crestor, the most powerful statin on the market, his total cholesterol was a beautiful 173, and his LDL was a respectable 101. But the good news ended there. His triglycerides were 176 (normal is less than 100), and his HDL was 37 (normal is greater than 50).
Jim's number belie a deeper truth about cholesterol that most conventional doctors are ignoring today: Given the current state of scientific understanding, the cholesterol numbers doctors measure today are increasingly irrelevant.
The Real Cause of Heart Disease
Instead of looking just at the cholesterol numbers, we need to look at the cholesterol particle size. The real question is: Do you have small or large HDL or LDL particles. Small, dense particles are more atherogenic (more likely to cause the plaque in the arteries that leads to heart attacks), than large buoyant, fluffy cholesterol particles. Small particles are associated with pre-diabetes (or metabolic syndrome) and diabetes and are caused by insulin resistance. Recent research (see my "Do Statins Cause Diabetes and Heart Disease" blog) indicates that statins may actually increase diabetes.
While measuring cholesterol particle size is a simple blood test that can be done at Labcorp, most doctors do not look at it, even though it is the only meaningful way to evaluate cholesterol numbers. You can have a LDL cholesterol that looks normal, like Jim did at 101, but you may have over 1000 small LDL particles which are very dangerous. On the other hand, you can have the same LDL number of 101, and it may be made up of only 400 large particles which cause no real health risk. Your health risk has less to do with your cholesterol numbers than it does the quantity and size of your cholesterol particles.
Again, we can take Jim as an example. His cholesterol particles were all small and dense because he had severe pre-diabetes. This is also not hard to diagnose. Jim was obese at 285 pounds with a BMI (body mass index) of 36. You are considered obese if your BMI is greater than 30. His waist-to-hip ratio was 1.04 (normal is less than 0.9 for men). He had very high insulin and blood sugar levels after we gave him a test drink of glucose (sugar). All this added up to tell us he had severe pre-diabetes or metabolic syndrome. As I mentioned before, he also had high triglycerides and low HDL-another clue that he had metabolic syndrome. We also found he had very low testosterone and growth hormone, further symptoms of pre-diabetes or metabolic syndrome.
Jim reported that despite working with a trainer he kept losing muscle and he was always hungry. This is why.
Let me reiterate: These are measurements and tests that can be done in any doctor's office, but are rarely done. These are not esoteric or expensive labs that can only be done at specialty clinics.
The condition that Jim suffered from, metabolic syndrome, is the most common medical condition in America, but the most rarely diagnosed. It affects over half the population. It is the major cause of heart disease, diabetes, and aging, and it is one of the major causes of dementia and cancer, not to mention infertility and sexual dysfunction. Yet it is mostly ignored by doctors. Why? The answer is simple and tragic: There are no drugs to treat it effectively, and doctors tend to focus on what they can treat with medications, even if it is the wrong target. This is one of the reasons statins are so popular in America despite the vast research against them.
Seven Tips to Fix Your Cholesterol (and Reverse Metabolic Syndrome without Medication)
Luckily, this doesn't mean you are doomed, even if you are already suffering from metabolic syndrome and heart problems. High cholesterol and pre-diabetes or metabolic syndrome can be successfully diagnosed and treated. I have reviewed this in previous blogs but here are 7 tips to help you get big large fluffy cholesterol particles and reverse metabolic syndrome.
1. Get the right cholesterol tests. Check NMR particle sizes for cholesterol by asking your doctor for this test at Labcorp or LipoScience. You want to know if you have safe light and fluffy cholesterol particles, or small dense, artery damaging cholesterol particles. A regular cholesterol test won't tell you this.
2. Check for metabolic syndrome.
Do you have a fat belly? Measure you waist at the belly button and your hips at the widest point-if your waist/hip is greater than 0.8 if you are a woman or 0.9 if you are man, then you have a problem
If you have small LDL and HDL particles, you have metabolic syndrome.
If your triglycerides are greater than 100 and your HDL is less than 50, or the ratio of triglycerides to HDL is greater than 4, then you have metabolic syndrome.
Do a glucose insulin challenge test. This is very important and most physicians do not test for insulin and glucose.
Check your hemoglobin A1c, which measures blood sugar over the last 6 weeks. If it is greater than 5.5, you may have metabolic syndrome
3. Eat a healthy diet. Eat a diet with a low glycemic load, high in fiber, and phytonutrient and omega-3 rich. It should be plant based, and you should consume plenty of good quality protein such as beans, nuts, seeds, and lean animal protein (ideally organic or grass fed). I have described specific diets that abide by these parameters in my book UltraMetabolism.
4. Exercise. Enough said.
5. Get good quality sleep. Sleep is essential for healing your body, maintaining balanced blood sugar, and your overall health.
6. Use supplements to support healthy cholesterol particle size. These include:
A multivitamin including at least 500 mcg of chromium, 2 mg of biotin and 400 mg of lipoic acid. For most you will take 3 capsules twice a day.
1000 mg of omega-3 fats (EPA/DHA) twice a day.
2000 IU of vitamin D3 2000 a day.
1200 mg of red rice yeast twice a day.
2-4 capsules of glucomannan 15 minutes before meals with a glass of water.
Broad-range, balanced concentration of plant sterols. You will usually take 1 capsule with each meal.
7. Consider using high dose niacin or vitamin B3. This can only be done with a doctor's prescription. It is useful to help raise HDL cholesterol, lower LDL cholesterol and triglycerides, and increase particle size.
8. Use low-dose statins ONLY if you have had heart disease or are a male with multiple risk factors, while carefully monitoring for muscle and liver damage.
For the vast majority of people this approach is better than simply taking a cholesterol medication. To reduce your risk of heart disease you need to address metabolic syndrome, and that can ONLY be done effectively with a comprehensive diet and lifestyle approach like the one outlined above.
Now I'd like to hear from you …
Have you taken statins, what has been the effect and do you have muscle pain or any neurologic side effects?
Do you think metabolic syndrome is an important factor to address to reduce the risk of heart disease? Why or why not? Has your doctor ever said, your sugar is a little high and we will watch it? What for what-until it is so bad you are eligible to take diabetes medication?
What do you think of conventional medicine's tendency to prescribe medications over dietary and lifestyle change for chronic health conditions?
I would love to hear your thoughts. Share them by leaving a comment below.
To your good health,
Mark Hyman, MD
(i) Cannon, C.P., Shah, S., Dansky, H.M. et al. 2010. Safety of anacetrapib in patients with or at high risk for voronary heart disease. N Engl J Med. 363(25): 2406-2415.
(ii) Barter, P.J., Caulfield, M., Eriksson, M. et al. 2007. Effects of torcetrapib in patients at high risk for coronary events. N Engl J Med. 357(21):2109-2122.
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