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Welcome all seeking refuge from low carb dogma!

“To kill an error is as good a service as, and sometimes even better than, the establishing of a new truth or fact”
~ Charles Darwin (it's evolutionary baybeee!)

Thursday, August 22, 2013

The Grand Carbohydrate-Cholesterol Switcheroo ~ Are We Repeating History?

In Deep Nutrition, one of the World's best health experts* Dr. Cate Shanahan writes this of cholesterol:
Genetic Experimentation—On You
You may have noticed the various cut-off levels over the years to identify people at “high risk” of a heart attack.  Years ago, if your total cholesterol was 300 or less, your doctor would have said you were fine. Soon, that number was lowered to 200.  Now people also watch their LDL, “safe” levels of which have been lowered from 200 to 160, to 130, to 100, and now 80.  Currently, the average person’s LDL level is still about what it’s always been, around 120–130. The controversial 2001 revision of the cholesterol guidelines means nearly half of the US population can now be labeled “high risk.”  And drug companies are raking it in.
She goes on to quote the former Medical Editor for NEJM stating that the reason this persists comes down to financial interests/conflicts.  To a considerable degree, I agree with Dr. Cate and her source on this one ... although I think the financial interests for the doctors are less about profit than liability, as well as the trend towards managing risk.  

One of the problems I run into as I debunk so-called "alternate hypotheses" is that I tend to come off on the side of the status quo ... by default, I suppose.  So I want to make it clear that I have never bought into the dietary cholesterol hypothesis.  In most, dietary cholesterol has little, if any, impact on fasting lipoproteins.  Having just listened to Jimmy's interview with Dr. Cate for his upcoming book Cholesterol Clarity, it seems an ongoing theme of the book will also be that total cholesterol levels are largely meaningless.  Again, I agree.   

However ... doctors have been measuring at least LDL and HDL for decades now, along with the somewhat misnomered "bad cholesterol" and "good cholesterol" designations.  I don't know of a single doctor who just does a TC test and puts someone on a statin.   I have always had high-ish (high normal to just above the cut-off) TC, but I've also always had a rather robust HDL number (60's-to-70's).  I do not have the numbers from that test back over a decade ago, but I did get the results in the mail in advance of the followup with the doctor.  They came with a standard printout generated by a computer and pointed out my LDL was a tad high.  I was prepared!  I planned to march into my doctor's office and declare myself just fine and how dare she suggest I might consider a statin.  Well, to my surprise her words were pretty much just that.  My other health markers were good (despite being quite overweight at the time) and she noted that my various ratios were great (yes, she looked!) and sent me on my way with an admonishment that I might want to lose some weight.  

Now, I'm sure there are those doctors who see the levels, gasp, and reach for the prescription pad.  But that hasn't been my experience and I'm willing to bet that it hasn't been most of yours either.  The unfortunate recent trending towards mandating drugs for insurance carriers is disturbing, but this will not be fought by bringing copies of mass media health rags to your doctor.   

Still, Shanahan makes a great point, and it is a point that has also been made concerning the "obesity epidemic".  No doubt Americans are getting heavier, but part of the problem is that the BMI thresholds have been scaled down.  Point being -- we've created arbitrary benchmarks by which perfectly normal people are all of a sudden sick or at risk for being so.

But the more conspiratorial amongst us are wont to believe there's a grand conspiracy between doctors and Big Pharma to rake in the bucks.  And when you can't make enough money off of the sick people, then test the crap out of the well ones and capitalize off of their fears with "risk assessments" and the magic pill you have for them that will allay their fears.    This may well have grains of truth to it, but as I put forth in Alternative Medical Ethics, this is not a tactic solely for the mainstream.  Indeed if you listen towards the end (~22 min or so for context) of this "bootleg audio" of Robb Wolf's Reno911 presentation at AHS13, you'll hear the Freudian slip that "it's much more profitable" to just go outside the establishment.  

But what of all of the bad advice based on bad science?  Sure, there are vestiges of "don't eat eggs" and "reduce saturated fat intake" around.  Need I remind folks that this is part and parcel of the Eaton/Konner/Cordain/Lindeberg paleo diet??!!  

But the renegades are not content to try to dispel myths and correct errors.  No.  They must find a new culprit.  First, it is that the fat doesn't cause obesity or high "cholesterol" it's the carbs.  In reality, however, carbohydrates, even fructose, are not significantly quantitatively converted to fats by the liver.  It is time for that "new" error or mistake to be corrected in the records.  Where lipids are to be dismissed as a "numbers game", blood glucose levels and the HbA1c have more than replaced them in that game, and sugar or starch as the demonized foods.    All of this is based on the misconception that carbohydrate content of the diet is what causes hyperglycemia. This is just wrong.  If one has a mild metabolic disruption, the symptoms can be managed with a low carb diet, but for those that LC works to reverse diabetes?  It's the weight loss that does the trick. 


Still, some time more recently, the diagnostic guidelines for "pre-diabetes" were lowered from a fasting blood glucose level of 110 mg/dL to 100 mg/dL (6.1 to 5.6 mmol/L).  This seemingly minor downward adjustment, however, ensnares a rather large proportion of the population -- the tailing bar that red arrow is pointing to on the distribution from this study.   The dots are actual frequency of deaths from all cause.    Importantly:

Lowest observed death rates centered on FBG** of 99mg/dL

If they centered on 99, then half of that group is above 99 mg/dL or "prediabetic". This is the data that prompted this quote from Ron "we are all diabetic" Rosedale (more in this blog post):
It is important to realize that this answer is no; there is no safe intake of sugar, nor a threshold level of blood sugar below which no harm will come, and I will shortly devote a fair amount of time to show this. 
The crux of the ‘safe starches’ argument is that no harm will come of this and it is, in fact, healthy. It is acknowledged that blood glucose will elevate after eating ‘safe starches’, but will generally stay below 140 mg/dl that Jaminet says is perfectly safe. Is it?? The science writing (below) is on the wall and the answer is…clearly no.
As well, there is no lacking for "there is no biological need for dietary carbohydrate" mantras in the low carb community.  Some, like Rosedale and Gedgaudas are fairly adamant that any dietary carb is unhealthy.  This is more extreme than the lipophobes, as even the USDA guidelines only call for limiting saturated fats to 10% of dietary intake (again, right around the amount used in the clinical trials of the "paleolithic diet").   

Perhaps one day as time permits, I'll flesh this post out some more, but at the moment it does not.  So I'll simply state that many of the same games are played with the HbA1c diagnostic.  Yes, risk and mortalities etc. track quite well when things go awry -- e.g. untreated, frank diabetes.  But we see similar trends here.  Within "normal" ranges there is high variability and little to no evidence that reducing this has any positive impact on health.  Indeed we see the same J curve where on the very low end you have increased risks again.  

Rationalizations in the LC-paleosphere aside -- that "physiological insulin resistance" is not the same as that bad kind,  and perhaps even protective should you find yourself cornered in a dark hallway at an obesity conference by Robert Lustig and jabbed with a bolus of insulin -- "prediabetes" is cause for immediate concern!  Jimmy Moore has written a whole book now to convince himself that his nightmarish lipid levels are nothing to worry about and he's perfectly healthy.  And yet his FBG is flirting with officially prediabetic and even eating almost zero carb didn't fix that.  So Jimmy is taking berberine supplements, which might as well be taking metformin, to control his blood sugar.   

Why?  

Is there not even a little bit of skepticism about the profiteering in the diabetes realm?  Seriously.  It seems the AARP is just about ready to hand out glucometers in place of membership certificates.  Have you seen all the commercials?   The conversion rates from prediabetes to diabetes is rather small.  So why is the low carb community contributing to mass hysteria over glucose levels, encouraging use of diabetes supplies (often expensive) by non-diabetics, and aiding and abetting the diabetes establishment?    At the very least, there is a big market for these alternate "practitioners" to profit off of fear mongering off glucophobes they've created with their hyperbole and flat out bad science.

Of course the medical establishment is excoriated for recommending the "wrong diet" (stupid diabetes doctors and their 8 Cokes a day dietary recommendations ...) and pushing drugs and insulin on actual diabetics.  But the community is filled with diabetics for whom diet alone has not brought their glucose metabolism back to normal (and I suspect many of these have the sort of potentially cautionary lipid profiles the Jimmy Moores will tell you not to worry about).  I get the impression that metformin is considered OK for these folks because you don't want your limbs to fall off and to go blind.  (And no I'm not making light of REAL complications from REAL diabetes ... that is serious and you should consult a REAL doctor for care in treating it.)

The parallels are there.  Are we repeating history here?  Seems like it.


* Title bestowed by Jimmy Moore, 2013.
** I left the FBG acronym because it's commonly used.  However both the study cited and the ADA guidelines are for fasting plasma glucose.  

42 comments:

Unpaleo said...

I got my blood tested for the first time 2 years ago (I'm 37). Had a high TC, but a very high hldl. Doc still wanted to put me on statins straight away. It does happen.

carbsane said...

Yeah, I was rushed at the end there. It does happen. It has happened with people I know. But firstly most of the time the docs will say let's try diet first. If LC is the way to go -- as they all say it is (and the claims are that LDL goes down on LC as well) -- then there shouldn't be a problem. But after that most docs will work with you, you just have to work with them too. Unfortunately you don't have a baseline to deal with. I had my first TC done at 19 for a job (working with hazardous chemicals so it was an extremely thorough workup -- took me a bit aback just how thorough and the company had a nurse discuss my results with me for over a half hour!!)

Kade Storm A.K.A. Hedonist said...

". . .it seems an ongoing theme of the book will also be that total cholesterol levels are largely meaningless. Again, I agree. "

I read this and got thinking about something that I don't quite understand or appreciate enough. If a cholesterol-sceptics party is arguing that total cholesterol is by and large a meaningless figure, then why even get into the futility of explaining the generally occurring fact that dietary cholesterol rarely raises fasting lipids? If total cholesterol does indeed not matter in any meaningful way, then the whole show doesn't matter. So why even pick away at something like dietary cholesterol not raising blood cholesterol--that within such context--comes across as an utterly trivial point?

Wuchtamsel said...

I agree with 99% of this great article.
But I want people to remember that dietary cholesterol actually HAS significant influence on the LDL-C levels in a significant part of the population! Variability is high and apoE4 carriers are probably those I'm talking about. I for myself can say, that only two eggs a day give me a rise in LDL-C of roughly 40-50 mg/dl. (I'm E4/E4.)

Nigel Kinbrum said...

Eating whole eggs does things other than raising LDL-c. See http://suppversity.blogspot.co.uk/2012/02/eat-whole-eggs-all-day-and-throw-your.html . Linoleic acid lowers LDL-c by concentrating it (& other stuff) in the liver, which isn't necessarily a good thing. β-carotene & γ-tocopherol reduce CHD risk factor by increasing the lag time, and egg yolks contain β-carotene & γ-tocopherol (also lutein & zeaxanthin).

Is there high quality evidence which shows that eating whole eggs raises CHD risk in anyone?

Wuchtamsel said...

My kind suggestion: Before answering a post, first read it.

Nigel Kinbrum said...

Thank you for your kind suggestion. I did read Evelyn's post and your comment before writing my comment.

Your comment implied that eating whole eggs is a bad thing, based on serum LDL-c level alone. My comment implied that there's a bigger picture.

What was your issue, again?

Wuchtamsel said...

So you suggest I should ignore a whopping rise of LDL-C from 140mg/dl to 190mg/dl and be happy about the additional carotenes and Vitamin E I get?
Yeah, for sure... If you don't recognize you are delusional, chances are you actually are.

Nigel Kinbrum said...

My LDL-c has been as high as 4.5mmol/L (174mg/dl) for quite a few years, though it's usually around 3.5mmol/L (135mg/dL) and I can still push my pulse rate to >100% MHR without getting chest pains or dropping dead. I'm in my late 50s.

TBH, the amount you worry about your LDL-c will probably kill you before the cholesterol does!

Wuchtamsel said...

Wow, that one really made me laugh...
Are you for real? You think not having angina tells you anything about the degree of subclinical atherosclerosis you are accumulating without any reasonable doubt? I wish you good luck, and that's not even meant ironic!

Nigel Kinbrum said...

Here ya go! http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2126116/pdf/9066473.pdf

400% higher CHD mortality, despite significantly lower LDL-c.

Wuchtamsel said...

You are really entertaining...
Ignoring the scientific evidence out of studies with literally 100.000s of participants and presenting a study with ~200 participants to prove your point "conventional science" to be wrong is so obviously stupid and ridiculous it's just priceless.

Nigel Kinbrum said...

Links, please. I'm not interested in epidemiological studies. Got any RCTs?

So what's the increase in CHD RR for an increase in LDL-c from 140mg/dL to 190mg/dL?

Wuchtamsel said...

If you really want to know the rise of the incidence of CVD for that given rise be so good and take a glimpse at the Framingham-data and then combine it with the results of the large interventional RCTs with different pharmacological treatments to reduce LDL-C.

RCT-data for lowering of LDL-C with drugs is essentially uniformal for resins, niacin and statins, and it's completely in line with what you would expect from the Framingham-data.
I'm not your brain extender by the way, if you really want to gain knowledge, so do it. But don't play the retarded fool who need to get his information predigested. There is not much in medicine as obvious, clear and proven as the role of LDL-C in the pathogenesis of CVD. And you won't change that with your gaga trolling.

Nigel Kinbrum said...

If you want to support what you say, the onus is on you to provide the evidence (as I have done). What did your last slave die from? ;-)

Wuchtamsel said...

No, this is utter nonsense.
The "evidence" you provided is a ridiculous cherrypicked study which is so small and meaningless, it's participants can't even be called a sample without your face turning red.
YOU are the one who is questioning the scientific evidence and it would be your duty to prove the scientific consensus is wrong! As you are obviously not even closely able to do so I call you what you are. A troll! This would be bad enough, but you are a troll actually risking the life and damaging the health of people who read and believe the BS you spew out.

Nigel Kinbrum said...

Would you like to explain the results from a new LARGE (120,000 subjects) study, in the link I just added to my previous comment?

Your resorting to personal insults shows who the real troll is, by the way.

carbsane said...

Nigel, stuff like this that takes years to develop can virtually never be studied with an RCT. Epidemiology is the best we're going to get.


It's fine if folks want to calculate and take their risks. That's pretty much my take-away from most of these studies anyway. For those sensitive to dietary agents that raise cholesterol though, I'd probably be better-safe-than-sorry were it me. We're talking minor changes in diet, not drugs here!

carbsane said...

They are proving something wrong and therefore saying that the rest of the hypothesis must also be incorrect. I agree in part. Whenever I hear the "saturated fats clog arteries" meme I cringe a little. But to take a page from the LC'ers that say the simplifications about insulin don't need to be correct so long as the rest of us get the point that insulin sux then it's OK.


I find the whole cholesterol doesn't matter but our diet improves it better anyway angle amusing ;-)

Karin said...

I think it's ridiculous they're using 99 mg/dl as the top end of the blood glucose range. Especially considering they're using plasma glucose and not whole blood glucose. For me, the plasma numbers are almost 15% higher. For one of my labs I tested my blood sugar right before and right after the blood draw. It was 85 mg/dl both times. My lab results came back with it at 97 mg/dl. I was momentarily shocked until I remembered it's plasma glucose. Do you think they came up with the range with whole blood glucose numbers in mind? Otherwise it really does look like they're trying to scare normal people into thinking they've got a problem.

carbsane said...

I am going to correct my post because I just always use the FBG acronym but that is misleading. There was an issue with one of the older studies Rosedale used that it made a difference (against his favor) but most of the "newer" studies use plasma glucose levels. It is also my understanding that most meters these days report plasma levels even though obviously whole blood is used.

In any case, I checked the study I cited here and it used data from the Paris Prospective Study. According to this paper it was " measurement of plasma insulin and glucose levels ". From http://en.wikipedia.org/wiki/Prediabetes the "ADA criteria: fasting plasma glucose level from 5.6 mmol/L (100 mg/dL) to 6.9 mmol/L (125 mg/dL)" (I note WHO still puts lower limit at 110).


So in terms of this study and the guidelines, the units/etc. are consistent.

Karin said...

Ok, I'm sitting here thinking to myself: Do I need to worry because my fasting blood sugar is almost at the top of the normal range?? Everything else on my labs was completely normal, including my cholesterol and triglycerides. But then I read what you have bolded.


"Lowest observed death rates centered on FBG of 99mg/dl"


So, why has the medical industry decided to set the upper limit at 99 then? It does seem to be based totally on hysteria and not on anything approaching science. Even though the hysteria about cholesterol seems to be waning, I doubt the "normal ranges" for it will ever change. So, now we will also be stuck forever will a nonsensical "normal range" for blood glucose too. If I think about this too much I will be propelled into the land of hating doctors and distrusting the medical establishment completely. So I think I will stop now, and just decide to not worry about it.

carbsane said...

I might just rattle a post off about this ;-) But in the mean time, I'd not get too peeved at doctors and the medical establishment as long as your doctor has a "it's just a guideline" approach and overall health approach.


If we look at cholesterol, this came about because there were more deaths from heart disease as we went through the 20th century ... so they started looking for the cause -- sugar or fat, etc.etc. For whatever reason they settled on the fat and the cholesterol gave them a predictive marker. It still holds true to some extent ... but then they were finding that too many were still having heart attacks without elevated LDL. So they figured, we need to catch this sooner or catch more at potential risk, so lets lower the threshold. It hasn't panned out very well but there's the momentum of a huge juggernaut to try to slow, stop or even reverse.


With glucose I see it as even more absurd because diabetes really does seem to almost be like a switch. You have nominal differences within a wide range -- even "mildly diabetic", and then the curves take off. There really doesn't seem to be any sort of benefit to lowering BG within normal ranges. I think the whole "prediabetes" thing came in again -- catch it early because then hopefully we can stop it or slow the progression. But FBG doesn't turn out to be a very great predictor.

carbsane said...

So I think in both cases the intent is good, the consequences not so much.

Nigel Kinbrum said...

"Epidemiology is the best we're going to get." I recall a study associating egg consumption with increased RR for diabetes. The problem is that if egg consumption is associated with toast consumption, is it the eggs or is it the toast that's increasing the RR for diabetes?

I recall another study implying that eating eggs is as bad as smoking cigarettes, using some dubious stats.

I believe that chronically worrying about slightly elevated LDL-c is worse than the effect of slightly elevated LDL-c.

Bris Vegas said...

The official Australian clinical guidelines say LDL subfractions have NO clinical significance. [Most pathology labs don't even offer LDL subfraction tests.]

In Australia medical care is mostly government funded. This means clinical practice is primarily based on evidence not advertisement driven patient demand.

Wuchtamsel said...

So what??? I haven't mentioned LDL subfractions once. And yes, they aren't used in Germany either. For good reason.

Nigel Kinbrum said...

Why are you waffling-on about irrelevancies like LDL sub-fractions and failing to comment on http://www.drbriffa.com/2013/08/23/research-finds-raised-cholesterol-to-be-associated-with-a-reduced-risk-of-death/ ?

An increase in LDL-c of 50mg/dL isn't "whopping" and won't cause you to drop dead at any moment, as I demonstrated using a CVD risk calculator. You can shove your hysteria about LDL-c where the sun doesn't synthesise Vitamin D.

Wuchtamsel said...

Wait a moment, wasn't it you who disregarded epidemiological data as irrelevant? I actually had a look at the paper and couldn't find a good explanation or reason why the results should be NOT explainable by reverse causation, even though "Dr." Briffa pulls that one out of his *** as being not possible.

Nigel Kinbrum said...

So you want to use epidemiological data when it suits you, but I'm not allowed to? Dr Briffa provided a link to a study showing that Iribarren's hypothesis is implausible. But your mind is made up, isn't it? You ridicule anything that counters your cherished beliefs.

What about the QRISK®2-2013 risk calculator at http://www.qrisk.org/index.php , which shows how unfounded your hysteria over LDL-c is?

Wuchtamsel said...

You realize that the results of the calculation and the influence of LDL-C is influenced by other confounding factors?
You don't know anything about me, not my age, not my BP and so on. So I have no idea for whom you calculated the risk increase you reported...
By the way, even if the risk increase is small in your view, it's still a COMPLETELY unnecessary increase in risk as we are actually talking about eating eggs or not! I agree I wouldn't bother adopting some ascetic extremists diet like Ornish & Co for a risk decrease of that given size but eggs or no eggs? Come on...

carbsane said...

I'm not saying they are without fault. Far from it. The prospective studies on various biomarkers are better but far from perfect as well. It's a risk benefit and even hunch thing I suppose at some point.


Personally I'm more concerned with the astronomical levels or dramatic changes. If my cholesterol shot up year over year I'd like to know why.

Nigel Kinbrum said...

"You realize that the results of the calculation and the influence of LDL-C is influenced by other confounding factors?"
Yes, I am aware that CVD is multi-factorial. See http://nigeepoo.blogspot.co.uk/2008/12/cholesterol-and-coronary-heart-disease.html , which I've just updated to mention ApoE4/E4.

carbsane said...

Briffa's study is ALL CAUSE so yeah, similar to the glucose study. There are other ways to go besides athersclerotic CVD.

Awful Will said...

Yes, that big study is astounding, isn't it? But wait, it is astounding because it disagrees with the overwhelming majority of previous studies. So is it more scientific to go with the majority of data or just the studies that disagree with the majority?

Awful Will said...

Yes, they are hedging their bets in appealing to that section of the buying public that might still be worried about high numbers.

Kade Storm A.K.A. Hedonist said...

That could very well be the case, but then I can't fault their critics for pointing out that they're simply puzzling that section of the buying public because any critically minded individual would naturally find such arguments about dietary cholesterol and 'our diet improves lipids' as being ones that undermine the other arguments about how lipids are irrelevant.

carbsane said...

That's one long but spot on sentence there Kade! :D

Nigel Kinbrum said...

What is this "overwhelming majority of previous studies" to which you refer? (A) link(s) to PubMed would be nice.

@ Wuchtamsel: If you'd said that you had homozygous familial hypercholesterolaemia, I would have said "O.K, don't eat many eggs". I'm not familiar with the term E4/E4. I just looked it up on http://en.wikipedia.org/wiki/Apolipoprotein_E#Polymorphisms I now know that it's bad.

Paul Casimir said...

My employer now has a mandatory "health assessment" that grants you a point score, with cholesterol stats being worth about 10% of the score. If you get penalized on the cholesterol score you have two options 1) pay more for health insurance premiums, 2) do a bunch of ridiculous "health" programs that allow you to make up the points. One of the health programs last year was 8 weeks of eating 9 servings fruits and vegetables per day, which was run during the winter because everyone loves a giant pile of tasteless out of season food.

Even if the cholesterol test has no value, it now affects me. By the way, last year I got dinged because my above-average HDL pushed my total to 202, 3 points above their limit.

Kade Storm A.K.A. Hedonist said...

Higher HDL should get one extra reward points, even on grounds of conventional, pro-establishment thinking.

robertmcastillo said...

High cholesterol itself does not cause any symptoms; so many people are unaware that their cholesterol levels are too high. Therefore, it is important to find out what your cholesterol numbers are because lowering cholesterol levels that are too high lessens the risk for developing heart disease and reduces the chance of a heart attack or dying of heart disease, even if you already have it.
Thanks
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