{"id":249,"date":"2014-05-14T14:23:27","date_gmt":"2014-05-14T14:23:27","guid":{"rendered":"http:\/\/joshmitteldorf.peachpuff-wolverine-566518.hostingersite.com\/?p=249"},"modified":"2014-05-15T02:15:57","modified_gmt":"2014-05-15T02:15:57","slug":"cholesterol-a-medical-controversy-i-background","status":"publish","type":"post","link":"https:\/\/scienceblog.com\/joshmitteldorf\/2014\/05\/14\/cholesterol-a-medical-controversy-i-background\/","title":{"rendered":"Cholesterol: A Medical Controversy &#8211; I Background"},"content":{"rendered":"<p><i>Cardiovascular disease is the #1 cause of death in the developed world, and for more than 50 years, standard medical advice has been that the best thing we can do to lower our risk of CVD is to reduce saturated fats in our diet. \u00a0The theory is that saturated fats lead to higher concentrations of cholesterol in the blood, and cholesterol in the blood leads in turn to formation of blockages that cause heart attacks. \u00a0There is strong, science-based opposition to this thesis, however. \u00a0Both parts of the inference have been attacked: \u00a0that saturated fat intake does not increase serum cholesterol, and that serum cholesterol does not cause heart attacks.<\/i><\/p>\n<p>&nbsp;<\/p>\n<p>When my daughter was still in kindergarten, her pediatrician told us that her blood cholesterol was high, that she probably had a congenital predisposition to high cholesterol, and that we should begin early to modify her diet to moderate her risk of hert disease later in life.<\/p>\n<p>Now my daughter is 28 and she asked me last week if she should be eating less chocolate and coconut to protect her long-term health. \u00a0I knew enough to know that the answer to her question was a subject of deep controversy, and I didn\u2019t know where I stood on the subject.<\/p>\n<p>In my daughter\u2019s honor, I am devoting this week and next to researching cholesterol and will report the results here. \u00a0Here are some questions I set out to answer. \u00a0(Please post comments suggesting your own).<\/p>\n<ul>\n<li>If your cholesterol is high because of diet, does this lead to increased risk of heart disease?<\/li>\n<li>If your cholesterol is high because of your genes, not diet, does this lead to an increased risk of heart disease?<\/li>\n<li>Does consumption of saturated fats lead to higher levels of blood cholesterol?<\/li>\n<\/ul>\n<p>These questions are elementary and the legitimacy of watching and treating blood cholesterol levels depends on the answers. \u00a0Assuming there is reason for \u201cyes\u201d, there are further questions:<\/p>\n<ul>\n<li>What foods contribute to high\/low cholesterol levels?<\/li>\n<li>Are there supplements that help to lower cholesterol? \u00a0If so, what is their effect on overall mortality risk?<\/li>\n<li>How does treatment with statins compare to treatment with diet and supplements?<\/li>\n<\/ul>\n<p>It has been standard practice among doctors for the last 50 years at least to treat serum cholesterol levels as a risk factor for heart disease, and to assume that there is a causal connection. \u00a0Half of Americans over 65 are taking prescription statin drugs (and \u2159 of people between 45 and 65) [<a href=\"http:\/\/www.health.harvard.edu\/blog\/statin-use-is-up-cholesterol-levels-are-down-are-americans-hearts-benefiting-201104151518\">ref<\/a>]. \u00a0It\u2019s clear that statins lower cholesterol in the blood, but whether the drugs lower risk of heart disease is less clear, and there may be no benefit at all for overall mortality rate [<a href=\"http:\/\/archinte.jamanetwork.com\/article.aspx?articleid=416105\" target=\"_blank\">ref<\/a>].<\/p>\n<p>The above questions are difficult because there is such a deep division of opinion in the medical community. \u00a0The mainstream view, which has the best data and the best studies behind it, is also suspect, in my mind, because so much of the science has been funded by the pharmaceutical industry. \u00a0Statin drugs are a $35 billion dollar industry in America, growing rapidly, and<a href=\"http:\/\/www.cholesterol-fact.org\/\" target=\"_blank\"> I have seen an estimate<\/a> as high as $200 billion per year worldwide.<\/p>\n<p>&nbsp;<\/p>\n<h1><strong>Differences in evaluations of statin drugs are stark<\/strong><\/h1>\n<p><a href=\"http:\/\/www.health.harvard.edu\/blog\/statin-use-is-up-cholesterol-levels-are-down-are-americans-hearts-benefiting-201104151518\">Here<\/a> is a semi-popular report published by Harvard Medical School health blog. \u00a0Peter Wehrwein notes that statin use is rising rapidly and heart disease deaths are falling rapidly.<\/p>\n<p><img loading=\"lazy\" decoding=\"async\" class=\"alignnone aligncenter\" src=\"http:\/\/hhpblog.s3.amazonaws.com\/blog\/wordpress\/wp-content\/uploads\/2011\/04\/Deaths-65-HUS2010.jpg\" alt=\"\" width=\"386\" height=\"408\" \/><\/p>\n<p>A meta-analysis published in Journal of the American Medical Assoc (<a href=\"http:\/\/jama.jamanetwork.com\/article.aspx?articleid=417802\" target=\"_blank\">1997<\/a>) concluded: \u201cThis overview of all published randomized trials of statin drugs demonstrates large reductions in cholesterol and clear evidence of benefit on stroke and total mortality. There was, as expected, a large and significant decrease in cardio-vascular mortality, but there was no significant evidence for any increases in either non-CV deaths or cancer incidence.\u201d<\/p>\n<p>A nutrition conference in Copenhagen (<a href=\"http:\/\/ajcn.nutrition.org\/content\/93\/4\/684.short\">2010<\/a>) produced the take-home message that every time an individual replaces 1% of the saturated fats in his diet with poly-unsaturated fats, his blood cholesterol decreases enough to afford a 2 to 3% reduction in risk of heart attack.<\/p>\n<p>On the other side, here is the conclusion of a meta-study (<a href=\"http:\/\/archinte.jamanetwork.com\/article.aspx?articleid=416105%20\">2010<\/a>) also published in the JAMA, pulling together results from 11 different studies over 40 years: \u00a0\u201cThis literature-based meta-analysis did not find evidence for the benefit of statin therapy on all-cause mortality in a high-risk primary prevention set-up.\u201d \u00a0Dr Fred Kummerow, author of <a href=\"http:\/\/www.amazon.com\/Cholesterol-Not-Culprit-Preventing-Disease-ebook\/dp\/B00IJ26UR8\">Cholesterol is not the Culprit<\/a>, was <a href=\"http:\/\/articles.mercola.com\/sites\/articles\/archive\/2014\/05\/11\/cholesterol-trans-fats.aspx\">featured by Dr Mercola<\/a> this week. \u201cOver the past 60 years, his research has repeatedly demonstrated that there\u2019s NO correlation between high cholesterol and plaque formation that leads to heart disease Dr. Kummerow\u2019s work shows that it\u2019s not cholesterol that causes heart disease; rather it\u2019s the trans fats and oxidized cholesterol that are to blame.\u201d<\/p>\n<p>Opposition to the standard hypothesis (saturated fats =&gt; High LDL =&gt; Stroke and heart attack) is not limited to the \u201cnatural medicine\u201d community. \u00a0It is broad and varied, some of it well-rooted in standard methodology of biochemistry and epidemiology.<\/p>\n<p>\u201cA meta-analysis of prospective epidemiologic studies showed that there is no significant evidence for concluding that dietary saturated fat is associated with an increased risk of CHD or CVD.\u201d (<a href=\"http:\/\/ajcn.nutrition.org\/content\/91\/3\/535.short\">2010<\/a>)<\/p>\n<p>I know of no other place in standard medical practice where the gulf between credible, opposing viewpoints is so vast. \u00a0I will continue to read, and next week promise to report what I can about why the disagreements are so deep and the contradictions so stark.<\/p>\n<p style=\"text-align: center\">&#8212;&#8212;&#8212;&#8212;&#8212;&#8212;&#8212;&#8211;<\/p>\n<p><strong>Basic chemistry<\/strong><\/p>\n<p><b>Petroleum oils <\/b>are simply chains of carbon atoms surrounded by hydrogen. \u00a0Each C can make 4 bonds, so most of the C\u2019s in the middle attach to one C on each side and two more H\u2019s.<\/p>\n<p><img loading=\"lazy\" decoding=\"async\" class=\"alignnone aligncenter\" src=\"http:\/\/www.chem.purdue.edu\/gchelp\/molecules\/decane.gif\" alt=\"\" width=\"341\" height=\"97\" \/><\/p>\n<p><b>Organic oils and fats <\/b>are \u201cfatty acids\u201d, which means that they differ from the simple chains by the addition of an \u201cacid group\u201d on the end. \u00a0An acid group has two extra oxygen atoms, and is written COOH.<\/p>\n<p><img loading=\"lazy\" decoding=\"async\" class=\"alignnone aligncenter\" src=\"http:\/\/www.foodnetworksolution.com\/uploaded\/StearicAcid.gif\" alt=\"\" width=\"583\" height=\"141\" \/><\/p>\n<p>These are all <b>saturated fats,<\/b> meaning \u201cas much hydrogen as the carbons can hold\u201d. \u00a0This makes more sense when we define an <b>unsaturated fat<\/b> as one that has double-bonded carbon atoms. Some C\u2019s instead of being attached to 2 C\u2019s and 2 H\u2019s have only 1 H. \u00a0They still have 4 bonds total, so they devote an extra bond to each other &#8211; a \u201cdouble bond\u201d between C\u2019s.<\/p>\n<p>Double bonds are more chemically reactive. \u00a0It is easier to break the chain at a double bond than at another place along the chain where there are only single bonds, and so fats with double bonds are more easily oxidized during cooking than saturated fats. \u00a0Unsaturated fats have a lower melting point, and are likely to be liquid at room temperature.<\/p>\n<p><b>Omega 6 and omega 3<\/b>: \u00a0These designations refer to the location of the double bond. \u00a0Omega 3 means that the 3rd bond is double, counting from the tail end, or omega end of the chain. \u00a0(The COOH is the head or \u201calpha\u201d end; the opposite end of the chain is the tail or \u201comega\u201d end.)<\/p>\n<p><b>Trans fat: \u00a0<\/b>Here\u2019s a curious and useful fact from chemistry: the atoms in a molecule are always vibrating, wiggling and bouncing around. \u00a0Part of this is rotation around each bond. \u00a0Single bonds can rotate freely. \u00a0But<b> double bonds cannot rotate<\/b>. This means that the double bonds create the possibility of two different forms of a molecule. \u00a0The part of the\u00a0chain on the right and the rest of the chain on the left of the double bond can be on the <b>same side<\/b>, creating a bent, V-shaped chain. \u00a0This is the \u201ccis\u201d form. \u00a0Or the\u00a0two parts of the chain\u00a0can be on opposite sides, so the double bond appears as just a kink in the chain, but not a bend. \u00a0This is the \u201ctrans\u201d form.<\/p>\n<figure style=\"width: 264px\" class=\"wp-caption aligncenter\"><img loading=\"lazy\" decoding=\"async\" src=\"http:\/\/healyourselfathome.com\/HOW\/NEWSTARTS\/1_NUTRITION\/FOOD\/FATS_AND_OILS\/HLFN\/HLFN_IMAGES\/oleic_acid.jpg\" alt=\"\" width=\"274\" height=\"190\" \/><figcaption class=\"wp-caption-text\">This is the &#8220;cis&#8221; form of oleic acid<\/figcaption><\/figure>\n<h1>In nature, one finds mostly \u201ccis\u201d fats. \u00a0<b>Trans fats <\/b>are mostly manufactured in food processing<\/h1>\n<figure style=\"width: 389px\" class=\"wp-caption aligncenter\"><img loading=\"lazy\" decoding=\"async\" src=\"http:\/\/www.cyberlipid.org\/images\/pict12.gif\" alt=\"\" width=\"399\" height=\"115\" \/><figcaption class=\"wp-caption-text\">This is a double bond in the &#8220;trans&#8221; configuration. There is no bend in the chain.<\/figcaption><\/figure>\n<p>Trans fats have a little kink in the chain, but the chain is basically straight. \u00a0\u201cCis\u201d fats are V-shaped molecules with a bend in the middle.<\/p>\n<p><strong>Cholesterol<\/strong><\/p>\n<p>Cholesterol is an essential, multi-purpose chemical, manufactured and used by every animal species and every cell within the animal. \u00a0Cholesterol gives cell membranes their pliability, and it is also used as a raw material for synthesis of hormones within a cell.<\/p>\n<p><img loading=\"lazy\" decoding=\"async\" class=\"alignnone aligncenter\" src=\"http:\/\/upload.wikimedia.org\/wikipedia\/commons\/thumb\/9\/9a\/Cholesterol.svg\/200px-Cholesterol.svg.png\" alt=\"\" width=\"200\" height=\"135\" \/><\/p>\n<p>The molecular structure is much more complicated than the fatty acids described above. \u00a0It contains four linked rings of carbon atoms, and one OH group in the lower left corner, making it technically an alcohol.<\/p>\n<p>Since cholesterol has very limited solubility in water, it is carried around in the blood by <a href=\"http:\/\/www.nlm.nih.gov\/medlineplus\/ency\/article\/007262.htm\"><b><i>lipoprotein<\/i><\/b><\/a>molecules that attach onto the cholesterol molecule at one end and dissolve in water at the other end. \u00a0High density lipoproteins (HDL) are called \u201cgood cholesterol\u201d, and low density lipoproteins (LDL) are called \u201cbad cholesterol\u201d, but whether this blood constituent is actually related to risk of heart disease remains in dispute.<\/p>\n","protected":false},"excerpt":{"rendered":"<p>Cardiovascular disease is the #1 cause of death in the developed world, and for more than 50 years, standard medical advice has been that the best thing we can do to lower our risk of CVD is to reduce saturated fats in our diet. \u00a0The theory is that saturated fats lead to higher concentrations of &#8230; <a title=\"Cholesterol: A Medical Controversy &#8211; I Background\" class=\"read-more\" href=\"https:\/\/scienceblog.com\/joshmitteldorf\/2014\/05\/14\/cholesterol-a-medical-controversy-i-background\/\" aria-label=\"Read more about Cholesterol: A Medical Controversy &#8211; I Background\">Read more<\/a><\/p>\n","protected":false},"author":65,"featured_media":0,"comment_status":"open","ping_status":"open","sticky":false,"template":"","format":"standard","meta":{"jetpack_post_was_ever_published":false,"_jetpack_newsletter_access":"","_jetpack_dont_email_post_to_subs":false,"_jetpack_newsletter_tier_id":0,"_jetpack_memberships_contains_paywalled_content":false,"_jetpack_memberships_contains_paid_content":false,"footnotes":""},"categories":[1],"tags":[],"class_list":["post-249","post","type-post","status-publish","format-standard","hentry","category-uncategorized"],"yoast_head":"<!-- This site is optimized with the Yoast SEO Premium plugin v27.4 (Yoast SEO v27.4) - https:\/\/yoast.com\/product\/yoast-seo-premium-wordpress\/ -->\n<title>Cholesterol: A Medical Controversy - I Background - Josh Mitteldorf<\/title>\n<meta name=\"robots\" content=\"index, follow, max-snippet:-1, max-image-preview:large, max-video-preview:-1\" \/>\n<link rel=\"canonical\" href=\"https:\/\/scienceblog.com\/joshmitteldorf\/2014\/05\/14\/cholesterol-a-medical-controversy-i-background\/\" \/>\n<meta property=\"og:locale\" content=\"en_US\" \/>\n<meta property=\"og:type\" content=\"article\" \/>\n<meta property=\"og:title\" content=\"Cholesterol: A Medical Controversy - I Background\" \/>\n<meta property=\"og:description\" content=\"Cardiovascular disease is the #1 cause of death in the developed world, and for more than 50 years, standard medical advice has been that the best thing we can do to lower our risk of CVD is to reduce saturated fats in our diet. \u00a0The theory is that saturated fats lead to higher concentrations of ... 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I Background\"}]},{\"@type\":\"WebSite\",\"@id\":\"https:\\\/\\\/scienceblog.com\\\/joshmitteldorf\\\/#website\",\"url\":\"https:\\\/\\\/scienceblog.com\\\/joshmitteldorf\\\/\",\"name\":\"Josh Mitteldorf\",\"description\":\"Aging Matters\",\"publisher\":{\"@id\":\"https:\\\/\\\/scienceblog.com\\\/joshmitteldorf\\\/#organization\"},\"potentialAction\":[{\"@type\":\"SearchAction\",\"target\":{\"@type\":\"EntryPoint\",\"urlTemplate\":\"https:\\\/\\\/scienceblog.com\\\/joshmitteldorf\\\/?s={search_term_string}\"},\"query-input\":{\"@type\":\"PropertyValueSpecification\",\"valueRequired\":true,\"valueName\":\"search_term_string\"}}],\"inLanguage\":\"en-US\"},{\"@type\":\"Organization\",\"@id\":\"https:\\\/\\\/scienceblog.com\\\/joshmitteldorf\\\/#organization\",\"name\":\"Josh Mitteldorf\",\"url\":\"https:\\\/\\\/scienceblog.com\\\/joshmitteldorf\\\/\",\"logo\":{\"@type\":\"ImageObject\",\"inLanguage\":\"en-US\",\"@id\":\"https:\\\/\\\/scienceblog.com\\\/joshmitteldorf\\\/#\\\/schema\\\/logo\\\/image\\\/\",\"url\":\"https:\\\/\\\/scienceblog.com\\\/joshmitteldorf\\\/wp-content\\\/uploads\\\/sites\\\/2\\\/2024\\\/09\\\/1058476001.jpg\",\"contentUrl\":\"https:\\\/\\\/scienceblog.com\\\/joshmitteldorf\\\/wp-content\\\/uploads\\\/sites\\\/2\\\/2024\\\/09\\\/1058476001.jpg\",\"width\":864,\"height\":363,\"caption\":\"Josh Mitteldorf\"},\"image\":{\"@id\":\"https:\\\/\\\/scienceblog.com\\\/joshmitteldorf\\\/#\\\/schema\\\/logo\\\/image\\\/\"}},{\"@type\":\"Person\",\"@id\":\"https:\\\/\\\/scienceblog.com\\\/joshmitteldorf\\\/#\\\/schema\\\/person\\\/214c5d1dad9f15c48f03128d5cfccdb1\",\"name\":\"Josh Mitteldorf\",\"image\":{\"@type\":\"ImageObject\",\"inLanguage\":\"en-US\",\"@id\":\"https:\\\/\\\/secure.gravatar.com\\\/avatar\\\/d3a8498f3d727156673030716d233edc57840f110d501b1b523e1780e9043b92?s=96&d=mm&r=g\",\"url\":\"https:\\\/\\\/secure.gravatar.com\\\/avatar\\\/d3a8498f3d727156673030716d233edc57840f110d501b1b523e1780e9043b92?s=96&d=mm&r=g\",\"contentUrl\":\"https:\\\/\\\/secure.gravatar.com\\\/avatar\\\/d3a8498f3d727156673030716d233edc57840f110d501b1b523e1780e9043b92?s=96&d=mm&r=g\",\"caption\":\"Josh Mitteldorf\"},\"description\":\"Josh Mitteldorf studies evolutionary theory of aging using computer simulations. The surprising fact that our bodies are genetically programmed to age and to die offers an enormous opportunity for medical intervention. It may be that therapies to slow the progress of aging need not repair or regenerate anything, but only need to interfere with an existing program of self-destruction. Mitteldorf has taught a weekly yoga class for thirty years. He is an advocate for vigorous self care, including exercise, meditation and caloric restriction. After earning a PhD in astrophysicist, Mitteldorf moved to evolutionary biology as a primary field in 1996. He has taught at Harvard, Berkeley, Bryn Mawr, LaSalle and Temple University. He is presently affiliated with MIT as a visiting scholar. In private life, Mitteldorf is an advocate for election integrity as well as public health. He is an avid amateur musician, playing piano in chamber groups, French horn in community orchestras. His two daughters are among the first children adopted from China in the mid-1980s. Much to the surprise of evolutionary biologists, genetic experiments indicate that aging has been selected as an adaptation for its own sake. This poses a conundrum: the impact of aging on individual fitness is wholly negative, so aging must be regarded as a kind of evolutionary altruism. Unlike other forms of evolutionary altruism, aging offers benefits to the community that are weak, and not well focussed on near kin of the altruist. This makes the mechanism challenging to understand and to model. more at http:\\\/\\\/mathforum.org\\\/~josh\",\"sameAs\":[\"http:\\\/\\\/AgingAdvice.org\"],\"url\":\"https:\\\/\\\/scienceblog.com\\\/joshmitteldorf\\\/author\\\/joshmitteldorf\\\/\"}]}<\/script>\n<!-- \/ Yoast SEO Premium plugin. -->","yoast_head_json":{"title":"Cholesterol: A Medical Controversy - I Background - Josh Mitteldorf","robots":{"index":"index","follow":"follow","max-snippet":"max-snippet:-1","max-image-preview":"max-image-preview:large","max-video-preview":"max-video-preview:-1"},"canonical":"https:\/\/scienceblog.com\/joshmitteldorf\/2014\/05\/14\/cholesterol-a-medical-controversy-i-background\/","og_locale":"en_US","og_type":"article","og_title":"Cholesterol: A Medical Controversy - I Background","og_description":"Cardiovascular disease is the #1 cause of death in the developed world, and for more than 50 years, standard medical advice has been that the best thing we can do to lower our risk of CVD is to reduce saturated fats in our diet. \u00a0The theory is that saturated fats lead to higher concentrations of ... 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The surprising fact that our bodies are genetically programmed to age and to die offers an enormous opportunity for medical intervention. It may be that therapies to slow the progress of aging need not repair or regenerate anything, but only need to interfere with an existing program of self-destruction. Mitteldorf has taught a weekly yoga class for thirty years. He is an advocate for vigorous self care, including exercise, meditation and caloric restriction. After earning a PhD in astrophysicist, Mitteldorf moved to evolutionary biology as a primary field in 1996. He has taught at Harvard, Berkeley, Bryn Mawr, LaSalle and Temple University. He is presently affiliated with MIT as a visiting scholar. In private life, Mitteldorf is an advocate for election integrity as well as public health. He is an avid amateur musician, playing piano in chamber groups, French horn in community orchestras. His two daughters are among the first children adopted from China in the mid-1980s. Much to the surprise of evolutionary biologists, genetic experiments indicate that aging has been selected as an adaptation for its own sake. This poses a conundrum: the impact of aging on individual fitness is wholly negative, so aging must be regarded as a kind of evolutionary altruism. Unlike other forms of evolutionary altruism, aging offers benefits to the community that are weak, and not well focussed on near kin of the altruist. 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