Part 3: The Low

In the last post we established that cholesterol is actually a necessary component of every cell in your body. We briefly discussed some of the things your body uses cholesterol for- things like making vitamin D and various hormones. Now let's take the time to talk about the other side of the cholesterol tail- when your cholesterol is too low. We'll break it down by talking about some of the things you make out of cholesterol.

The sex hormones Estrogen, Testosterone, and Progesterone are all made from cholesterol. While the ovaries and the testes are more than capable of making their own cholesterol, the vast majority of cholesterol in the body is made by the liver(1). Thus, when you don't have enough of their precursor, cholesterol, it would be logical to think you might develop hormonal imbalances as a result.

The adrenal glands- also known as the suprarenal glands, are two triangular shaped glands that sit atop the kidneys. These tiny glands make a multitude of different hormones, most of which are derived from cholesterol. The most famous of these hormones is the so-called "stress hormone", cortisol. Cortisol and melatonin control the sleep-wake cycle, which is also called the circadian rhythm. When the adrenals don't have enough reserve to make cortisol, they can become exhausted. This is known as adrenal fatigue (more to come on this later) and can lead to things like chronic fatigue, trouble getting to sleep or staying asleep, trouble getting up, and gut and brain related symptoms.

Vitamin D is one of only two vitamins the human body is capable of making on it's own, and is incredibly important for gut healing(2), immune function(3), and most famously, calcium metabolism. Studies across the board have shown that vitamin D deficiency is the most common vitamin deficiency in the developed world, with as many as 40-90% of people being deficient(4). If you haven't gotten your vitamin D levels measured lately, it's well worth getting done. Luckily, vitamin D supplements are relatively inexpensive- but remember to take it with a meal with some fat. Vitamin D is a fat soluble vitamin, and will be best absorbed when eaten with other dietary fats so that the liver and gallbladder have a chance to emulsify it with bile salts.

Speaking of which, bile salts are another thing made from cholesterol. Bile is synthesized in the liver, which then is collected and concentrated in the gallbladder. I'll talk about the gallbladder and the consequences of removing it in a later post, but for now we will go over basic physiology. Bile is secreted from the gallbladder in response to the ingestion of dietary lipids (fat). Without bile acids, any fat you ingest would pass straight through the tubes and not be absorbed. I know that sounds like a good thing to a lot of people, but it's really not. Fat is a vitally important part of every cell in your body, particularly omega-3 fatty acids which are very anti-inflammatory.

As you can see, cholesterol is an extremely important part of your body. Because of this, most functional medicine doctors like to see cholesterol that is somewhere between 150-200. But now that we've covered what can happen as a result of low cholesterol, let's discuss some things that may cause low cholesterol.

Most commonly decreased cholesterol is seen in a pattern with other blood markers that are indicative of malabsorption. When you are unable to absorb the nutrients in your food, you can't make things like cholesterol, nor any of it's downstream metabolites. When this is the case, the most effective way to treat the patient with low cholesterol is often times a gut-healing protocol, which we will discuss in later posts. Conveniently enough, when you heal the gut it has a tremendous anti-inflammatory effect across the entire body.

Another interesting angle to look at is the debate about chronic infections and their impact on the body as a whole. In the article Mafia Wars(5) the author mentions that many critters (bacteria, namely) need cholesterol to stabilize their own cell membranes, and it is believed now that these bugs have the ability to steal our cholesterol. There has only been limited research on this so far, but it's an intriguing concept as the world learns more about infectious organisms such as H. Pylori, E. Coli, and Borrelia, the causative agent behind Lyme Disease.

Until next time,

References:
(1) Guyton and Hall Textbook of Medical Physiology pp 847-848
(2) Juan Kong "Novel role of the vitamin D receptor in maintaining the integrity of the intestinal mucosal barrier" Am J Phsiol Gastrointest Liver Physiol 294:G208-G216 October 2007
(3) Kamen, Diane. “Vitamin D and molecular actions on the immune system: Modulation of innate and autoimmunity” J Mol Med 2010 May; 88(5): 441-450
(4) http://www.sharecare.com/question/how-common-vitamin-d-deficiency
(5) http://classic.the-scientist.com/2010/6/1/40/1/

Part 2: The Necessary

If you got into a conversation about cholesterol with someone off the street, they would most likely start talking about hypercholesterolemia, or high cholesterol. The conversation would no doubt touch upon topics such as low-cholesterol diets, statin drugs, and perhaps even exercise. But what about the unspoken other side to the cholesterol story? Nobody ever tells us just how important this 27 Carbon beauty is. Cholesterol is not an evil molecule the gods have cursed us with, but rather, the unsung hero in much of human physiology.

Though we talk an awful lot about cholesterol itself, this molecule is far from the end of the road in this physiological map. Quite the contrary, actually. Cholesterol is the mother molecule to many familiar substances in the body such as the sex hormones Estrogen, Testosterone and Progesterone, Vitamin D, the adrenal hormone Cortisol, and Bile Acids. Cortisol is the famous "stress hormone", but also plays a crucial role in the circadian rhythm and keeps your blood sugar stable while you sleep. Bile acids are the main constitute of bile, which is released made in the liver, but is ultimately released from the gallbladder to aid in fat digestion and absorption. Cholesterol also plays a vital role in keeping our cell membranes flexible, and making our skin water-proof(1). Of course, having cholesterol that is too low can negatively affect these pathways. For this reason, most functional medicine doctors (more on that later) like to see cholesterol that is somewhere between 150-200, while most conventionally trained doctors will tell you "the lower the better" in regards to your cholesterol.

As with most things that are this vital to our health, our bodies can make their own cholesterol. Actually, the vast majority of cholesterol is made by your body, rather than ingested(1). The ingestion of dietary cholesterol has little, if any affect on one's total cholesterol levels. There are two primary reasons for this: 1. The majority of exogenous (ie. what you eat) cholesterol is esterified, or in a form that is relatively difficult for our bodies to absorb and 2. Rising levels of cholesterol provide a "negative feedback loop" to the enzyme that is chiefly in charge of cholesterol synthesis (HMG-CoA Reductase). In other words, your body knows better than to keep making cholesterol when you already have enough, so there is a signal to that enzyme that says "enough". This then brings up the question, how is it that anyone has high cholesterol, then? Something must be pushing that enzyme to make more cholesterol despite the negative feed-back loop...

In enters insulin. Insulin is a hormone that is secreted from the pancreas in response to a rise in blood sugar (glucose). This hormone has many roles in the body, but it's most famous (and probably most important) is to bring glucose into the cells. As your blood sugar levels rise, insulin levels are not far behind. The amount of insulin your pancreas secretes is directly related to the amount of sugar in your blood, which of course is directly proportional to the amount of sugar (and to a lesser extent, carbohydrates) in the food you eat. More sugar consumed --> More insulin secreted. It has now been shown that insulin up-regulates the rate-limiting enzyme in cholesterol synthesis (HMG-CoA Reductase)(2). Thus, high blood sugar (ie. diabetes and insulin resistance) directly leads to increased synthesis of cholesterol. Add to this the fact that the per-cursor molecules that make cholesterol can be made from sugar (Acetyl-CoA), and one can easily see why diabetes and high cholesterol often go hand in hand.

The trouble is, most conventionally trained doctors and nutritionists put their patients on a low-fat, low-cholesterol diet when they see high cholesterol in a lipid panel. While this doesn't seem like a bad idea in and of itself, low-fat diets are often laced with unbelievably high amounts of sugar. One prime example of this is yogurt. While brands like Yoplait boast their fat-free and low-fat labels with pride, these supposedly healthy snacks often have upwards of 28-30 grams of sugar per serving! Ever since the low-fat campaign of the 1980s, countless low-fat and fat-free snacks have appeared on grocery store shelves, but for what? Americans are more unhealthy than we were in the 1980s, and many experts trace this back to the initiation of the low-fat campaign. I, for one, am among those that say sugar is far worse for you than fat ever thought of being- weather that be so-called "natural sugars" like maple syrup and honey, or artificial sugars. The two exceptions to this are saturated fats and trans fats, which are found in greasy animal products and hydrogenated oils like margarine, respectively.... But we'll go more into detail on the low-fat versus low-carb debate in a later post.

So go ahead, eat those egg yolks. There's other things on that breakfast table that are scarier than eggs, anyway...

Stay healthy,

References:
(1) Guyton and Hall Textbook of Medical Physiology pp 847-848
(2) Dietschy JM "Effects of alterations of the specific activity of the intracellular acetyl CoA pool apparent rates of hepatic cholesterogenesis" J Lipid Res 1974;15:508-516

Part 1: The High

According to the CDC heart disease is the number one cause of death in the United States, accounting for approximately 25% of all deaths. In 2010 coronary heart disease alone cost the United States 108.9 Billion dollars(1). In 2010 Lipitor was the number 1 selling prescription drug in the United States with sales over 7 Billion dollars(5).

But is high cholesterol really to blame like we have been lead to believe? Is a Lipitor deficiency really the culprit behind these heart disease related deaths, or is something else at play here? That's not to say that statins such as Lipitor don't do a good job of lowering the so-called "bad cholesterol", in fact, they do a darn good job of it. However, they do nothing for correcting the underlying physiology that caused the high cholesterol in the first place. If your car was speeding out of control and you wanted to bring it to a stop, would you put a foot on the breaks, or take the foot off the gas? Of course anyone in their right mind would do both, but you get my point. Statins put a "brake" on your body's ability to make cholesterol, but do nothing to take your foot off the proverbial "gas". Only dietary and lifestyle changes can do that, my friends.

So what are you to do if you are among the one of six Americans(2) who have high cholesterol?

1. Ask your doctor to check other heart-disease related markers. Half of all people who suffer a heart attack have normal cholesterol, so this is a good idea even if you don't think you are at risk. Atherosclerosis (hardening of the arteries) is an inflammatory process, so monitor your body's inflammatory load with tests such as C-Reactive Protein (CRP), Homocysteine, and Omega 6: Omega 3 ratio. If most of us took a good, hard look at ourselves I bet we would admit that we're probably inflamed but seeing the test results in black and white makes it almost impossible to ignore.

2. Make lifestyle and dietary changes to dampen inflammation. Cut out the crappy processed foods- Really. We all know they're not good for us, even if the shiny label boasts claims such as "33% more fiber" or "reduced fat". Eat more vegetables (Fresh, ideally, but frozen will do in a pinch). Play outside more. Drink water. Take supplements such as Omega-3 Fatty Acids and Curcumin that will pump up your body's antioxidant stores.

3. If you and your doctor decide to try a statin ask questions such as:

1) Is this particular statin the right choice for me? Why are they prescribing this one as opposed to another one? Make sure you ask this question if you are put on Crestor. Crestor is the strongest of the statin family and has a bad reputation for causing more side-effects than it's milder counter-parts(3).

2) How much do you need to drop your LDL? In most cases, people only need a 20-30% reduction in LDL, which can be accomplished with much smaller doses than are typically prescribed. For example, the manufacture's recommended starting doses for Lipitor are 10, 20 and 40 mg however, the 2.5 mg dose reduces LDL by 20-25%(3).

3) Know the side-effects of the drug you are on. Statins cause side-effects in an alarming amount of people- up to 42% of people taking them(3). Among the most alarming (and common) are liver and heart damage (4). Ask your doctor to monitor your liver and muscle with tests such as LDH, AST, ALT, Bilirubin, BUN, and GGTP.

4) Take CoQ10 daily. CoQ10 is an antioxidant that is found in the mitochondria of your cells, and is depleted by statin drugs. It is involved in energy production in the electron transport chain- a process that happens in the inner membrane of the mitochondria of your cells and is absolutely critical for ATP production. Because the enzyme that is inhibited by statin drugs is relatively early in the process of cholesterol synthesis, decreasing activity of this enzyme also inhibits the formation of other down-stream molecules such as CoQ10.

4. Ask your doctor to test your Apo E geneotype. This so-called "Alzheimer's gene" dictates how your body uses fuel (carbs, protein and fats), and may have more to do with your cholesterol levels than once thought. For more information on this "perfect gene diet" visit http://perfectgenediet.com/apoe_gene_diet.

More to come soon.

Stay healthy, planet Earth.

References:
(1) http://www.cdc.gov/heartdisease/facts.htm
(2) http://www.cdc.gov/cholesterol/faqs.htm#6
(3) What You Must Know About Statin Drugs and Their Natural Alternatives by Jay S. Cohen, MD
(4) http://www.mayoclinic.com/health/statin-side-effects/MY00205
(5) http://www.pharmacytimes.com/publications/issue/2011/May2011/Top-200-Drugs-of-2010

"When diet and exercise aren't enough" is almost always the opening line in statin (cholesterol lowering) drug commercials. They'll finish off the sentence with "when diet and exercise aren't enough, lipitor/crestor/other brand can help lower your bad cholesterol". These commercials often start with a healthy looking man saying "I thought diet and exercise were enough" or "I wish I had listened to my doctor sooner". In both cases, the drug company wants you to identify with the person in the commercial- they want that "wow, he's just like me!" response.

I find the above statement really irritating for a number of reasons.

1. None of these people seem to remember that we need cholesterol for a multitude of bodily functions. Nearly all of your hormones are made from cholesterol, as well as bile (which you need to digest fats), the antioxidant CoQ10, and vitamin D. Cholesterol keeps your cell membranes fluid. Cholesterol isn't bad- we need it.

2. By this point, many of you realize that I see things differently than most doctors. So many things that are labeled as disease are actually symptoms of something deeper. Like so much else that I see in my clinic, I often see high cholesterol as a symptom of something bigger. Hypothyroidism? Metabolic syndrome? Hormone deficiency? Adrenal fatigue? Statin drugs don't do squat to fix those problems- they only suppress your body's cry for help.

3. Statins aren't very safe. Statin use (and low cholesterol levels) has been repeatedly linked with neurodegenerative diseases and diabetes, to name a few. It's really not shocking once you see cholesterol in this new light, though. I mean, that high cholesterol is probably a cry for help. For example, if you have consistantly high blood sugar, your body can take that sugar, make it into acetyl-coa, and turn it into cholesterol. In this case, high cholesterol is actually saving you from the inflammation of high blood glucose. If you cut off that pathway your body has no avenue to get rid of sugar and badda bing, badda boom- diabetes.

Lastly, and perhaps most importantly, the diet the American Heart Association recommends (one high in carbohydrate and low in fat and cholesterol) is the exact opposite of what you should do to bring down your cholesterol levels. The higher your blood sugar creeps from all those carbs the more your body will be forced to make more cholesterol. It should also be noted that this diet is generally pretty inflammatory. Cholesterol is not the enemy. Inflammation + Cholesterol is, however, a potential problem. Not only is the "heart healthy" diet not doing you any favors- I would bet that it's doing much more harm than good.

So when the drug companies say "when diet and exercise aren't enough", I believe what they really meant to say is:

For more reading on cholesterol:
The Great Cholesterol Con
Dr. Joseph Mercola's Article
Gary Taubes, Author of Good Calories, Bad Calories
My Older Blog Posts

If you or somebody you know is interested in working with a functional medicine doctor please call my office at (919) 238-4094 and see if we are the right fit for you. Infinity Holistic Healthcare is located in Chapel Hill, North Carolina, part of the Raleigh-Durham "triangle" area.

In health,