Myths & Truths of Cholesterol

I recently sat down with Dr. John Gildea to discuss a question that came in about someone on the Ketogenic Diet whose cholesterol when up.  In this conversation, we cover cholesterol, the ketogenic diet, salt and vitamin D3.

Transcript:

David Roberts:

Great. So hi, my name is David Roberts. Today, I'm with Dr. John Gildea and we're founders of Mara Labs.   And we're going to talk a little bit about cholesterol. We've been talking a lot in my Wednesday Wellness Blogs about ketogenic diet. And we had one question that we thought was worthy of just a little bit more discussion, and that's cholesterol. So, we had somebody email in, "Hey, I've been doing ketogenic diet and my cholesterol has been inching up." And so if you just wanted to dive into that and John, maybe just start from the beginning. What is cholesterol?

John:

Yeah. So it's a very long and old studied subject. I think a lot of times you get clarity when you read some of the earliest papers on the subject. And so I don't know the exact date where these papers were done, but it was I think in the 40s or 50s where they were able to track cholesterol for the first time. It was interesting, I think the first paper I remember reading that startled me, it was kind of an unknown thing to me, was that the paper basically, I think it was in Coats, which is interesting. But the interesting part about it was that the paper's conclusion was that cholesterol is the most regulated metabolic compound in the body. Like, if you eat zero your body makes the equivalent of like three grams of it. If you ate three grams of it or more it makes zero.

John:

For me, the next important part about that is that cholesterol is actually mobilized to sites of injury. It's called tropism. So cholesterol is necessary for repair. So for instance, you take an organ like a kidney and you damage it, an influx of cholesterol will come to the kidney in order to facilitate repair, because cholesterol is really important for membranes to be able to move things and repair. So that's the second thing.

David Roberts:

That's part of what's called the lipid bilayer?

John:

Yeah. Yeah. So the plasma membrane and the internal membranes, cholesterol is really important for keeping it fluid like. Yeah, so cholesterol is really, really highly necessary for that. And then I think the other piece of information in order to understand the complexity of this is that when you go to the doctor, you're not actually measuring cholesterol.

David Roberts:

Okay.

John:

You're measuring lipoprotein. So it's the proteins that are carrying cholesterol. So LDL is the low density lipoprotein. And then HDL is a high density lipoprotein. But there's a whole bunch of lipoproteins in the body, all different sizes. And they do the shuttling of cholesterol basically to and from the sites in your body that need cholesterol. So I think some of the biggest findings that are out there is that originally they just thought it was the total amount of cholesterol determined whether you got heart disease. I think that's been pretty much abandoned. It's not the total level. And doing the sub fractionation of proteins, it's the ratio of the size and density of the lipoprotein.

John:

So classically, I think big headway was done when they could measure what's called the depth band, which is interesting, is a high form of low density lipoprotein. So it's called the sdLDL, small dense LDL. So the smallest version of a low density lipoprotein, that's bad.

David Roberts:

That's the death thing?

John:

Yeah, death band. And then the other band on the other opposite side of the ratio is called hdLDL 2, and it's on the bigger side of the HDL. So that tends to move cholesterol away from sites. And so the ratio of sdLDL to hdLDL 2B, it is this ratio that is a decent predictor Of your chance of heart disease.

John:

So I think the hard thing to put together there is that if you just take a statin, that stops your production of cholesterol.

David Roberts:

Yes.

John:

It does very little to change the ratio of LDL, HDL, all these sorts of things. So just the amount of cholesterol in your blood is not a very good predictor of disease. I need to know the statin had been shown to be really good statistically because they're measuring 100s of 1000s of patients. The percent improvement is very small. So the only really solidly proven evidence that I can find of statins in heart disease is if you've had a heart attack, is to lower your total cholesterol for the next 10 years. And then that benefit goes away if you go over age 70.

David Roberts:

And so is cholesterol content, is that very dynamic and is it easy to change?

John:

Total cholesterol amount?

David Roberts:

Yeah.

John:

I don't really know because I don't think the total amount really has anything to do with anything. It's really that it has to be there, it's necessary and that it's necessary for repair. And the total amount that you have is not a problem unless you have a genetic problem.

David Roberts:

What about the ratio, is that easy to change?

John:

Yes. And the ratios to change is the... If you kind of summarize a lot of research, the HDLs are very responsive to exercise, strenuous exercise. And then the LDLs are a combination of things, mostly inflammation, vitamin D status. And those are the big ones because the site where the small dense LDL cholesterol accumulates in the endothelium where you get cardiovascular disease is an inflamed sight. Basically, decrease the inflammation, you decrease your chance of getting that atherosclerotic plaque.

David Roberts:

And is that risk part of the reason there's a decent amount of research on [inaudible 00:08:21] and pregnancies?

John:

Yes. That's a big component of it is inflammation. And then also how you handle calcium is a big component too. So one of the big breakthroughs in heart disease risk status is called the EBCT. It's a way of measuring calcium in your coronary arteries. And if you get a baseline and then measure it again in a year's time point, if this calcium score goes up beyond a certain point, your chance of having a heart attack in the next five, 10 years goes up dramatically. And if you do maneuvers such as reduce inflammation, increase exercise, vitamin D status, deal with calcium, which is often your, what do you call it, vitamin K2 status, if that calcium score doesn't go up in the next year your chance of having a heart attack goes down. I think I remember the major study from that was 17 fold, which there's never been a study on heart disease that shows that big a change from a baseline.

David Roberts:

Is that study available?

John:

Yeah.

David Roberts:

Yeah, that'd be great. So you mentioned vitamin D, I have more questions on cholesterol, but do you take a vitamin D supplement daily or maybe weekly?

John:

I would stop in the summer if I ever got outside.

David Roberts:

Even in Virginia?

John:

Yeah. You need, I guess at this latitude and I guess the two or three months in the summer you have to have full body exposure for, I think it's 30 minutes to get adequate.

David Roberts:

And so you supplement, how many IUs do you take - is it daily or every other day?

John:

So I used to be really careful. So when they were doing a lot of vitamin C personalized medicine stuff and tracking this cholesterol plaque addition, they were trying to find an exact number where you would take it. And I think a lot of things pointed to an exact amount of vitamin D, it's like 1000 international units for every 25 pounds of body weight, which would be 6,000 international units for a person that's around 150 pounds. I think that's probably a rough estimate that's good for most people.

David Roberts:

That's daily?

John:

Yeah, daily. But really there've been a couple of grassroots movements to try and figure out what's the right dosage. And it turned out from a lot of experimentation that if you take vitamin A and vitamin D at the same time, you're 25-hydroxyvitamin D3 status in your blood goes to optimum if you take a lot or as long as you take enough. And you don't get the hypervitaminosis. So it's kind of a long story, but if you take excess vitamin A, you get vitamin D deficient if you're not taking vitamin D. So that's where the bad statistics for vitamin A come from. It's if you go above 3000 or are immune to vitamin A, you'll start seeing some morbidity increase.

John:

But I think what that's doing is harming the people that have low vitamin D and giving them immune dysfunction and those kinds of complex disease states are tough to unravel. But then you're in the epidemiology world though.

David Roberts:

So I'll rephrase my question as far as what ideally would you want during the day, 1000 IUs?

John:

I think a minimum.

David Roberts:

A minimum. And a follow-up question to that, some of the vitamins that have the D3s have vitamin K too, and K7, would you recommend including that?

John:

Yeah, so vitamin K's job is to regulate calcium basically. And that's the harm that you get if you take too much vitamin D. Vitamin D, when it's converted by the kidney to its final functional form is, I forget the name of it, but it has the word calcium in it. I forget the name of it. The final functioning unit. So that's the harm in having too high of Vitamin D. And also push back on high vitamin D if you take vitamin K too.

John:

So it ends up going to the right place. The right place for calcium is mostly your bones and not in your arteries. You want stiff bones and fluidic arteries, not the opposite, glass arteries and loose bones.

David Roberts:

And circling back around, D3 is important for cholesterol because it helps with arteries?

John:

D3 is a big regulator of inflammation.

David Roberts:

So and a location of inflammation could be the circulatory system?

John:

Yeah. And because of the way they circulatory system works, the places where there's not two routes of blood flow to the tissue is where getting atherosclerotic plaque has the most harm. So heart or any place in your heart, there's one coronary artery that feeds it. So if you get a blockage there, that part of the heart dies and then that part of the heart becomes, it's called an ectopic flow sign. It starts a new electrical signal, which is what a heart attack is. If you get that developing over time, you can get what's called anastomosis, you can form a secondary artery that will join another artery and bypass a block.

John:

So brain and heart are the two places where you just have one artery feeding one tissue. And that's where blockages show up, heart attacks, strokes.

David Roberts:

And so basically high cholesterol and specifically the improper ratio, so bad to good, people talk about that as far as the cause of blockages, the cause of plaques, the cause of heart attacks.

David Roberts:

Is that true? And what parts of that are true and what parts maybe aren't?

John:

Yeah. It's a number of factors that all have to line up in the bad for that to happen. That vitamin D status, lack of vitamin K2, inflammation, so your calcium is high, your small dense LDL is high and then you have sites of inflammation that are in the coronary arteries and you start building up atherosclerotic plaque there. So those are a bunch of things that are poor and it takes quite a bit of time for that to happen. And so the way to oppose that is to get all of those line up in the right direction and get the right kind of pressure. And a lot of people don't even realize that you can reverse plaque. You can actually mobilize plaque from the site and decrease that coronary artery blockage with the correct pressure over time, exercise, decreased inflammation, not being overweight is a big thing too.

David Roberts:

So as far as exercise goes, what would be sort of, let's say we have somebody listening who is like, "I want to start exercising." What would be a good amount of time and then what would they build to?

John:

Yeah, I wish Martin was here. He's...

David Roberts:

Martin, yes, so we'll actually do an exercise conversation with Dr. Katz.

John:

That's his shtick

David Roberts:

His MO, his bread and butter. Yes, but he's not here, so I'll let you give...

John:

Give it a shot.

David Roberts:

Give it a shot. And we learned from Charlottesville. And so there's a quote at University of Virginia athletic facility about Thomas Jefferson saying 15 minutes of exercise every day will lead to good health.

John:

That's pretty good. I think if you try to get up to date on what's going on in the exercise health world, I would say that sort of the biggies are, I think people realize that a pure sedentary life is really bad. They're just sitting still. So the first thing you want to do is get up and move a lot. So don't just sit still for a long time. Get up at least every hour, every half hour and get enough movement. They're finding that atrophy happens rather quickly. So if you can do anything to just get your muscles moving a little bit, even stretching seems to activate that muscle to prevent atrophy. So then once you get past just you're not atrophying, you're not in the sedentary category, then I think the next step is to do enough exercise once a day, so that you do a really good job of moving your lymphatics. So you do enough exercise with enough repetitive, strong muscle contraction that you're draining your lymphatics. Because your lymphatics don't have a heart, they just have valves. And the only way they move is by pressure contractions, that kind of traction and movement.

John:

So I think the 20 minute walk, the half hour walk seems to be adequate for that. And then if you want to step it up another step, it will be some form of high intensity exercise. So high intensity would be anything where you get your heart rate really going up at least for a short periods of time.

David Roberts:

To what level, what beats per minute?

John:

So in the case of the, I think it's the firing of the ultra high, fast-twitch fibers, that would be getting close to your maximum, your maximum heart rate. So that's 220 beats minus your age. So if you're 50, it'd be 170. So get it to 170. And then resistance is another level where so much of blood glucose regulation and things like that is muscle mass. It's this sugar sink that you have all the time. And so the more muscle mass you have, the bigger sugar sink you have. And I think preventing what's called sarcopenia, is your age-related loss of muscle mass.

David Roberts:

And we talk about that on the blog with the methyl hydroxy methyl-butyrate that you have the paper on, and we'll have a link to that, a little bit about the metabolic syndrome and that.

John:

Yeah. So it's good to think about exercise in increments there where if you're completely sedentary, now the first step is don't be. However you do that, stand up at a standing desk or just set a timer and stand up and walk around once an hour. If you can then add in there something like leaning into your desk, do 10 pushups at an angle, do a couple squats, mix it up and do a little bit of stretching. That would be the next level. Then from there, increase again and you make sure you're doing a walk or something, either walk...

John:

My kids really like jumping on a trampoline, that seems to help me a lot. So jumping on a trampoline. And that seems to be the best lymphatic drainage out there. And then burst resistance training. If you're young enough, sprinting or doing it in the midst of play, I think is another one, make it fun.

David Roberts:

Great. So last topic on cholesterol. So circling back to the genesis of the question, ketogenic diet, cholesterol is going up, shooting up, what's going on there? And just the question poised was does the avocados and the almonds contribute to that or what's going on when cholesterol goes up during keto?

John:

If I make just a few assumptions, I can make guesses at it. Of course, you'd want to sit down with an integrative medicine doctor to really get at that one, especially if you're worried about it. But one of the things that I think a lot of people do in a ketogenic diet incorrectly is they're not keeping up on their minerals. So it's known that if you don't keep up on your salt in particular or potassium, magnesium, so the three are sodium chloride, potassium, magnesium, then you can start a little bit of an avalanche that is not good. You need sodium chloride for making the right amount of acid in your stomach. Your nerves need sodium, so those are what I would guess is happening. A good way to just talk about this in general is that I think a great way to think about nutrients in general is all you have to do is remove one nutrient and your body responds with the same reaction.

John:

You get increased reactive oxygen species, you get genomic instability and bad things happen, inflammation would be one of them. And so if you miss or are deficient in any one of those either micronutrients and in particular minerals, which are problems that you're not keeping up with them, you can start an avalanche where you'll get inflammation and a lot of these things. My guess is that might be what's happening. And then you're getting some organ dysfunction and your body is responding to that by sending cholesterol.

John:

So you're mobilizing cholesterol to repair an issue and that's the reason why your cholesterol is higher.

David Roberts:

Right. I like that. Just since we're on it and you mentioned it, why does the ketogenic diet lead to less salt?

John:

So one of the major ways that salt is reabsorbed by the kidney is with sugar. So sugar causes sodium to be reabsorbed. And then sugar also is just a, what do you call it, it carries water. It's an osmolite. So when you go into a ketogenic diet, you are getting rid of, you're dramatically lowering your amount of sugars in your blood. And so you're not reabsorbing as much salt. So you have to increase the amount of salt you take in so it just doesn't spill out into your urine. And that's also part of the benefit that happens from it too, is sugar is involved in inflammation so your inflammation goes dramatically down. And so if you're not taking in these electrolytes, at some point that benefit switches and then you have your low salts and there's all kinds of things that happen from low salt; low potassium, low magnesium.

David Roberts:

Yeah. I remember after my wife died, I would get two months into keto, the ketogenic diet, hardcore and about six weeks in, in the evening, I texted you because I was in tachycardia and a-fib, it was like my heart was a bowl of Jello. I was like, "Could this be because my salts are messed up?" you were like, "Yes." And so I made a concoction of magnesium, potassium, sodium chloride, and just chugged it, chugged a glass, and within 20 minutes everything was fine … severe those conditions can get.

David Roberts:

Like my dad who worked in anesthesiology, obviously he worked in the emergency room. He was always surprised how many conditions are cured by an IV. So many people that are throwing up or have diarrhea or both or are elderly, an IV, they should just put an IV in every person that comes through the door, unless it's... Some of it's blood loss too, I was going to say, unless you have a cut.

John:

Yeah, blood volume is a big one. If you're not pumping blood around well - blood and oxygen, you're in trouble.

David Roberts:

Yeah. And that ketogenic diet also hydration is important.

John:

Yeah, staying hydrated for the same reason.

David Roberts:

So great. Well, thank you, John. And I hope this is a helpful conversation about cholesterol and ketogenic diet and just cholesterol in general. So if you like this conversation, please click on the link below and if you guys are on social media feel free to like us on Instagram and follow us on Facebook. We're on both. So thanks again. Thank you, John, and we'll talk to you next time.

 

 

 


1 comment


  • Lee Grove

    Fantastic information guys. Thank you! There’s so much that is left out on blood tests because the overall objective seems to be: "Read it, if they’re in the standard “normal range” then report it & prescribe if they aren’t."
    So many subtle yet important considerations are overlooked or left out on some of the standard blood tests. Thank you for the deeper information and facts. Much appreciated! -Lee


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