Cholesterol Part 3 - How Can We Reduce Our Risk?
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Cholesterol Part 3 - How Can We Reduce Our Risk?


In this third and last post on cholesterol and Coronary Artery Disease (CAD) we will talk about what you can do to lower your risk.  In the first post we broke down the myths of the Lipid Hypothesis (located HERE) and in the second we covered what really causes Coronary Artery Disease (CAD) (located HERE).

As I eluded to in the first post, CAD is primarily caused by oxidative damage and inflammation.  The 4 primary causes of oxidative damage and inflammation are:
  1. Poor Nutrition
  2. Stress
  3. Smoking
  4. Physical Inactivity
Let's break each these factors down.

Smoking

So we all know we shouldn't smoke.  Smoking as few as 1-4 cigarettes a day increases your CAD risk by 40%.  40 a day increases risk by 900%!!   I don't think I need to say much more on that one.

Physical Inactivity

We also know that being physically active is important.  People that are not physically active have 1.5x to 2.4x the risk for heart disease.  Currently more than 60% of Americans are not regularly active and 25% are completely sendentary.  Regular excessive reduced both inflammation and oxidative damage.  There are many ways to increase your physical activity.  It doesn't mean you have to go to them gym and run on a treadmill.  Just going to the grocery store, parking at the far end of the lot, shopping for your food and coming home to cook a meal instead of going through the drive through can make a difference.  Walk around the block and increase from there.  Walk the dog.  There are a lot of activities that we can do to increase our excessive and reduce our risk of heart disease.

Stress

Stress is important to keep low as this can be a big contributor to CAD risk.  This Study showed that stress can triple the risk of heart disease.  This is when we get that "fight-or-flight" response that we experience when under high stress.  This elevates cortisol which causes both oxidative damage and inflammation. A great way to reduce stress and increase physical activity is with something like Yoga!

Poor Nutrition

The best thing you can do to influence your risk of CAD is through diet.  This study of 52 countries found that 90% of heart attacks could have been prevented through diet.  That's right, 9 out of 10 heart attacks could be prevented without drugs.  So what foods cause oxidative damage and inflammation?  There are several sources and we will break down the biggest ones.  This biggest contributors to oxidative damage and inflammation are sugar (sucrose, fructose, etc), starch (grains, etc), polyunsaturated (PUFA) oils and trans fatty acids (transfat).

Sugar!
One of the best studies on sugar consumption and how it relates to cholesterol levels is the 2011 study by Peter Havel and colleagues titled Consumption of fructose and HFCS increases postprandial triglycerides, LDL-C, and apoB in young men and women.  In this study they had 3 groups in a randomized trail and had them consume the Standard American Diet (SAD) (55% carbs, 15% protein, 30% fat) with the difference being where the carbs came from in each group.

Group 1: 25% of their total energy from glucose (so traditional sources, sort of the SAD control group)
Group 2: 25% of their total energy from fructose
Group 3: 25% of their total energy from High Fructose Corn Syrup (HFCS) (55% fructose and 45% glucose)

This 25% of their diet coming from sugar equals about 120 pounds of sugar per year.  That may sound like a lot, but that is actually below the current average for Americans.  This figure shows the differences in LDL-C, non-HDL-C, apoB, and apoB/apoA-I.

This is a very powerful indication that while glucose and fructose alone can be bad in excess, their combination seems even worse.  It would have been really interesting to have an additional group that removed most carbs all together.  (more on this in the carb section below)

Sugar and fructose are very inflammatory and cause lots of oxidative damage.  What happens is when we consume large amounts of sugar and fructose, our insulin levels go up and it is this rise in insulin that causes tears in the artery wall.  Cholesterol comes to repair this oxidative damage and build up causing plaque build up (as described Here in part 2).  So it is imperative to keep our blood sugar levels (and thus insulin levels) balanced so that we don't cause this inflammation and oxidative damage.  So keeping sugar and starch low in our diets (to keep our blood sugars balanced) becomes the best way we can change our diet to reduce our chances of getting CAD.

Also important to note, as I did in This post, non-alcoholic fatty liver disease and metabolic syndrome are very big factors in CAD risk (as much as 14 times in women).  So what causes non-alcoholic fatty liver disease?  There is growing evidence that fructose consumption (fruits, fruit juices, etc) are a big contributor as well as high fructose corn syrup (source and source).  When you consume fructose 100% of the metobolic burden rests on your liver.  Only your liver can break it down.  Glucose is only 20% broken down by the liver and the remaining 80% is immediately metabolized and used by the cells in your body.  When fructose is converted into fat, it gets stored in your liver and other tissues as body fat.  120 calories of fructose is stored as 40 calories of fat in your body.  120 calories of glucose gets stored as less than 1 calorie in your fat stores. Fructose metabolism is very similar to alcohol making it one of the biggest contributors to non-alcoholic fatty liver disease.

Fructose also worsens insulin resistance which speed metabolic syndrome.  This is a good video with more info on sugar.

Carbs
There is a great study by Jeff Volek that looks at the results of a carbohydrate restricted, high fat diet compared to a low fat high carb diet and the results on cholesterol (source).
The two groups in the study were taken from a SAD diet to a carb-restricted diet (CRD or Very Low Carb, High fat diet) and low-fat diet (LFD or Very Low Fat, High Carb diet).  As you can see the high fat diet was mostly fat (100g or 900 calories) and very little carbs (44g or 176 calories).  Here are the results after 12 weeks on each diet.

As you can see the Low Carb/High Fat diet reduced Triglycerides significantly and also reduced insulin levels greatly.  The Low Fat diet had statistically insignificant changes in both triglycerides and insulin levels.  As we discussed in the last post, LDL particle number is the best predictor of CAD risk, but other measurements like Triglycerides can be indicative of issues that can contribute to high LDL-P.  It is good to keep your fasting Triglycerides below 88.  

Good Fats
This is the component you want to increase the most (while decreasing carbohydrates) to help protect against heart disease.  Especially important are saturated fatty acids (SFAs).  Saturated fats like coconut oil, butter, ghee, tallow and lard are protective against oxidation and inflammation and have many other important health benefits.  I will have a post on fats coming soon to expand on this topic in greater detail. Studies like This one published in the Journal of Nutrition 2004 showed that saturated fat from MCT oil (medium-chain fats similar to those in coconut oil) and beef tallow reduced alcohol-induced liver damage when substituted for polyunsaturated corn oil. In fact, they replaced 20 percent, 45 percent, or two-thirds of the corn oil with saturated fat and found that the more saturated fat they used, the greater the protective effect.  So saturated fat can be protective against one of this biggest risk factors for CAD, fatty liver disease.  Here is another recent study showing the protective affects of coconut oil.  There are several good oils that can be very helpful in reducing your CAD risk.  Also, the higher the saturated fat content the better.  Here are the best oils:

  1. Coconut oil: 1.9%  PUFA (92% saturated fatty acids (SFA))
  2. Palm kernel oil 2% PUFA, (82% SFA)
  3. Cocoa Butter: 3%  PUFA (60% SFA)
  4. Beef Tallow: 3.1%  PUFA (49.8% SFA)
  5. Ghee: 4% PUFA (48% SFA)
  6. Butter: 3.4% PUFA (50% SFA)
  7. High Oleic Sunflower oil (9% PUFA)
  8. Macadamia oil: 10% PUFA (15% SFA)
  9. Avocado oil: 10% PUFA (11% SFAt)
  10. Lard: 12% PUFA (with 41% SFA)
  11. Duck fat: 13% PUFA (with 25% SFA)
  12. Almond oil: 17% PUFA (with 8.2% SFA)
  13. Olive oil: 9.9% PUFA (with 14% saturated fat) (although this one should never be used for cooking which will cause oxidation.  So only use in dressings, etc.) 
So we should be consuming lots of these oils in order to reduce our CAD risk (as well as a huge number of other health benefits). Many studies have shown that the higher the saturated fat intake in the diet leads to less fat in the bloodstream (source).  Where as the same study showed that low fat diets where carbs were high, had higher fat in the bloodstream.

Bad Fats
There are two kinds of fats that should be avoided.  The most inflammatory fat is Trans Fatty Acids (transfat). Transfats are one of the worst substances we can consume for our overall health.  There are many studies that show the heart disease and cancer risks of transfat (source, source, and many more for cancer, source and source).  Even the FDA has stated that "Further reducing trans fat consumption by avoiding artificial trans fat could prevent 10,000-20,000 heart attacks and 3,000-7,000 coronary heart disease deaths each year in the U.S." Here is a list of transfats to avoid:

  • Margarine
  • Vegetable Shortening
  • Ingredients that list Hydrogenated (fully or partially) Oils

Poly Unsaturated Fatty Acids (PUFA's) are also bad oils as they are easily oxidated.  This means they are very susceptible to oxidative damage, the thing that increases our CAD risk.  There are many PUFA oils and here is a short list:

  • Grapeseed oil: 70.6% PUFA
  • Sunflower oil: 68% PUFA
  • Flax oil: 66% PUFA
  • Safflower oil: 65% PUFA
  • Corn oil: 54.6% PUFA
  • Walnut oil: 53.9% PUFA
  • Cottonseed oil: 52.4% PUFA
  • Vegetable oil (soybean oil): 51.4% PUFA
  • Sesame oil: 42% PUFA
  • Peanut oil: 33.4% PUFA
  • Canola oil: 19% PUFA
What has happened over the last 100 years is a huge increase in PUFA consumption and a reduction in other good fats (like saturated fat).  Here is a chart showing the increase in PUFA consumption in the US.
It is my belief that this is a big contributor to our increase in heart disease.  So it is imperative to reverse this trend if we want to reduce the incidence of heart disease.

Note: PUFAs are essential fatty acids, so we do need them in our diet.  When it comes to PUFAs, the type and how you handle them is very important. When using PUFAs, try to use them without heating too much (salad dressings, etc) to keep them from being oxidized and store them in the refrigeration to keep them from getting rancid (omega-3s like fish oil, flax, etc). The ratio of Omega-3s to Omega-6s should be closer to 1-to-1, but today many people eat a 1-to-20 or even 1-to-50 ratio of Omega-3s to Omega-6s.  Omega-6s are also inflamitory when consuming too many and Omega-3s are anti-inflammatory.  So it is important to make dietary fat intake from more saturated fats and less PUFAs and make the PUFAs we do eat a ratio closer to 1-to-1 of Omega-3s to Omega-6s. (Lots more about this Here)

Summary

There are many things you can do to reduce your risk of coronary artery disease (CAD).  Some of these are obvious (quit smoking, reduce stress, increase physical activity).  But nutrition can be the largest factor (preventing as much as 90% of heart attacks).  The biggest nutritional contributor to CAD risk is sugar.  High fructose corn syrup and fructose are particularly bad but all sugars will contribute and should be eliminated as much as possible.  Other starchy foods also contribute to oxidative damage and inflammation so keep starchy food consumption as low as possible also helps CAD risk.  Lastly, the good fats (saturated fats, coconut oil, MCT oil, ghee, butter, tallow and cocoa butter) are very protective against oxidative damage and inflammation and should be consumed in high quantities in order to reduce your risk of CAD.  The bad fats are the transfats should be completely avoided.  PUFA's should be limited and kept at a 1-to-1 ratio with Saturated fats or less.  Eating lots of good fats, moderate amounts of protein and very low carbs (especially sugars) are the best ways to reduce your CAD risk.  In addition supplementin with CoQ10 can help decrease oxidation and improve heart health.





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