Cholesterol…What’s the real story on how to treat it?

So your doctor told you that you have "high cholesterol" and recommended a "statin" drug such as Lipitor or Simvastatin.  Or, perhaps your doctor is more motivated to deal with causes rather than symptoms and suggested you clean up your diet by cutting out eggs and red meat and getting some exercise.  According to the guidelines for Internal Medicine, in which I am board-certified, lifestyle and diet modification are supposed to be the first step in management of high cholesterol, particularly for high triglycerides.  But your levels are still too high and now, again, you get the prescription...

But is there something else going on here?

The answer may well be a resounding "YES"!

I and other physicians have been classically trained in our residencies to view high cholesterol, particularly high triglycerides and high LDL, as a disease in itself-rather than a symptom of disease.  This plays right into the hands of the drug companies who want to sell statin drugs or drugs to treat high triglycerides.  Unfortunately, the benefits to this approach are really quite small with very few people spared deaths from heart attacks or strokes by taking these drugs and the side effects can be severe.  But what else can be done?

Years ago, I began to wonder if we were missing something more important than just absolute levels of LDL or triglycerides.  And furthermore, why is the liver churning out these excessive amounts of LDL when it didn't do so when the patient was younger?  And most teenagers don't have great diets, yet they still have mostly good cholesterol numbers...Why is that?

After studying this problem and treating patients, I have come to believe that while there are a few people who have hereditary high cholesterol due to genetic defects, the vast majority of people have high cholesterol due to the chronic effects of poor diet (see here for more on this) or suboptimal hormones.

To create a plaque in an artery requires 2 things: a high level of oxidized cholesterol particles (LDL, Lp(a), etc) and a damage to the endothelial wall (the inner blood vessel wall).  The cholesterol sticks to the damaged area and infiltrates into the artery wall leading to inflammation and eventual blockage of the artery.  Statin drugs lower LDL by reducing the production of cholesterol by the liver but don't stop it from oxidizing, so even though the levels are lower, it is still dangerous.  Statin drugs also don't fix the damaged arterial wall surface.  That's why people still do get heart attacks while on statin drugs.

The damage to the blood vessel wall is due to a diet high in polyunsaturated  fats (vegetable oils), free radicals, and refined sugars which cause endothelial dysfunction, exposure to toxins such as heavy metals (causing free radical damage and endothelial dysfunction), deficiencies of nutrients such a vitamin C, and methyl-B12/methyl-folate, (again causing endothelial damage), chronic inflammation (autoimmune disease or infections) causing endothelial damage, or finally and very significantly, deficiencies in the steroid hormones or thyroid hormones that are needed to regulate the function of endothelial cells.

Here is the hormonal theory, advanced in a  medical article by a Dr. Dzugan in 2011.  The liver makes the steroid hormones from cholesterol, so when there are relative deficiencies in these hormones, it makes more cholesterol to try and increase levels of these hormones.  That's it.  Dr. Dzugan reports that he has tried replacing these various steroid hormones and when needed thyroid hormones and documented some amazing results:  The average total cholesterol dropped from over 229 to less than 184!  The drop was due to a decrease in LDL (the "bad" cholesterol) but the HDL(the "good" cholesterol) remained unchanged.  And the patients reported a much better quality of life, despite getting older!

So those teenagers who live on junk food?  According to this theory their cholesterol is relatively good because they have an abundance of steroid sex hormones, thyroid hormones, and adrenal hormones!

However, this leaves out the connection between high cholesterol and heart disease.  It's nice to lower cholesterol numbers, and one can do this with drugs as well as these hormones, but what I really care about is whether my patients are preventing a heart attack or a stroke-not just what the numbers are.

Some people with higher cholesterol don't get heart disease while other do.  Why is that?  Well, If the excess cholesterol becomes oxidized, the oxidized LDL particles stick to the artery wall in areas of damage.  It is as if the LDL is trying to "patch" these raw areas of damage.  What caused the damage? Sugars, polyunsaturated fats, trans fats, free radicals, hypertension with blood flow turbulence, toxic metals, deficiencies of needed nutrients, chronic inflammation or infection, and so on, and lack of hormones needed to regulate the function of the cells lining the arteries.

The interesting thing is that we know that all these things are linked to mortality from heart disease and stroke!

Note: If you want to know if you have oxidized cholesterol, you need to get a test called a "VAP". This is a simple and cheap blood test done by all major labs such as Quest or Lab Corp.  You want the large LDL particles called type "A".  You don't want the small type B oxidized particles which cause arterial damage and blockage.  If you have type B, you are in danger, even if your levels of cholesterol are good and you need to see a doctor trained in functional medicine who knows how to correct this problem and thus reduce your cardiac risk.  There is no pharmaceutical drug to convert type B LDL to type A.

 So, by eating a high carbohydrate diet, smoking, a high content of oxidized fats or trans fats in the diet, low consumption of plant antioxidants, or other factors as mentioned above, this cholesterol made by the liver turns into oxidized LDL and does indeed cause vascular damage by sticking to the artery walls in areas that are damaged from many factors already mentioned and results in eventual clogging of the arteries and heart attacks.  The conclusion would be that lowering LDL alone, without addressing all these other factors will not improve the health of the artery and will not improve mortality from vascular disease very much.  This is what we see with conventional drug therapy such as the statin drugs.  The slight reduction in death rates seen with the statins are due to an antiinflammatory effect they exert on the artery, NOT the reduction of LDL levels.

So, the answer to reducing the risk of cardiovascular disease as well as lowering cholesterol would seem to be a multi-pronged approach:

1.  Correct diet: I recommend the Paleo-Mediterranean diet, avoiding polyunsaturated fats(vegetable/canola oils), emphasizing omega-3s and extra-virgin olive oil. Eat healthy saturated fats (coconut oil, free-range egg yolks, grass-fed organic meat fats, butter from grass-fed cows).  A correct diet is low in the sugars and polyunsaturated fats that damage arteries and provides the vitamins and antioxidants needed by the arteries to remain healthy.

2.  Optimize all steroid hormones based on blood testing: Estrogens, Testosterone, Progesterone, Pregnenolone, DHEA, D3 are all important and must be brought to optimal ranges.

3.  Optimize thyroid hormones.  Hypothyroidism is a known cause of high cholesterol.

4. Nutritional support for arteries:  Vitamin C in liposomal form, methyl folate, methyl B12, P5P, Betaine, plant-based antioxidants, resveratrol, quercetin, pomegranate, etc.

5.  Remove heavy metals if present.  Heavy metals generate free radicals that can damage the arteries.  A recent study of intravenous chelation therapy (TACT study, 2012) showed an improvement with respect to vascular disease, likely due to this mechanism.

6.  Stop chronic inflammation that is damaging arteries by correcting any autoimmune disease or chronic infection.  It is well-known that people with autoimmune disease develop accelerated atherosclerosis.

7.  Last resort, if a patient is unable or unwilling to do the above or has high lipids despite this effort (in which case it is probably an hereditary problem).  Consider drug therapy.  But even if using drugs such as statins, one can reduce the risk of side effects by taking Coenzyme Q10 with the drug and supplementing with the hormone called pregnenolone.  Some articles suggest that using red yeast rice combined with CoQ10 is an even better alternative with fewer side effects.

So, It's a lot more complex than simply writing a prescription for a drug isn't it?  But the human body is infinitely complex and the one-drug-for-one-problem approach doesn't work so well here as in many cases.

I have used this approach in many of my patients and have achieved optimal cholesterol numbers in most  of them without resorting to drugs; but remember, the cholesterol numbers are the symptom-not the cause of the problem.  I want to focus on health, not just numbers on the cholesterol test.  I also want to know if the cholesterol is oxidized (Type B) or not (Type A).  When the numbers and type of LDL are optimal, I am then confident that the patient is now healthy metabolically, their hormones are optimal, they have been detoxified and nutritionally restored and their arteries (and the rest of their body) are functioning normally.  I anticipate this will result in greater health in the long run without toxic side effects.  That's what every good doctor wants for their patient.

If you have high cholesterol or cardiovascular disease and would like to explore this approach to treatment, please feel free to contact my office.

In Health,

Dr. Joseph Kaye