Chapter 85
Lower, and for longer
There is a reason why statins aren’t mixed into the drinking water to pump the whole population full of them. Yes, it would be fantastic if everyone had low cholesterol, but the drugs themselves come with countervailing risks. That’s why physicians usually prescribe statins at the highest possible dose. That way, they achieve the greatest possible lowering of LDL cholesterol without increasing the risk of muscle damage that the drugs can cause. Statins also increase the risk of type 2 diabetes. If, however, you lower your cholesterol level with lifestyle changes, you get only the benefits—including a markedly lower diabetes risk. But is it possible to lower LDL enough through diet alone?
If you ask some of the nation’s leading cholesterol experts what levels they aim for, you’ll probably hear an LDL under 70 or something similar. Simply eating less saturated fat and trans fat, as found in meat, dairy products, and industrial junk, and less of the cholesterol found especially in eggs, probably won’t be enough to get most people to the desired target. After all, those who eat a completely plant-based diet can reach such a low LDL as an average value. No wonder that a predominantly plant-based diet is the only one proven to reverse the progression of coronary heart disease.
Pressure points
There is a similarly dead-normal paradigm when it comes to blood pressure. We know that the leading risk factor for premature death in the United States is diet, tobacco is in second place, but in third we find high blood pressure, also called hypertension. High blood pressure is so dangerous because it increases the risk of dying from many different diseases, from heart disease and stroke to heart and kidney failure.
See see.nf/bloodpressure on how the guidelines have evolved, but the bottom line is that the risk of death from stroke or heart disease rises exponentially as blood pressure rises, starting around 110/70. If, however, you were to lower blood pressure with drugs that drastically, it would have unacceptable consequences. For example, if you gave high-risk patients enough medications in sufficiently high doses to get their blood pressure down to an upper value of about 120, you could prevent 100 000 deaths and 46 000 cases of heart failure every year. At the same time, you’d have to be prepared for it to cause, for example, 43 000 cases of electrolyte imbalance and 88 000 cases of acute kidney injury. So you can see the dilemma guideline committees face.
On the one hand, lowering blood pressure is good for the heart, kidneys, and brain, but beyond a certain point, the side effects of medications could outweigh their benefits. Our goal is to lower patients’ blood pressure as much as possible, but if we use medications to do so, then only “when the effects of treatment are likely to cause less harm than the high blood pressure.” The problem is that most people who die of heart disease, heart failure, or a stroke hover at the threshold—they are at risk, but not high enough to justify medication.
If only there were a way to lower blood pressure without drugs—then you could have it both ways. Fortunately, there is: regular aerobic exercise, losing weight, quitting smoking, eating more fiber, drinking less alcohol, eating more plants, and less salt. The benefits aren’t limited to avoiding negative side effects. Lifestyle changes such as switching to a plant-based diet are actually better than medications, because you treat the underlying cause and enjoy healthy side effects, too.
Lower, and for longer
On the typical American diet, atherosclerosis, the hardening of the arteries, can begin as early as the teenage years. Researchers took about 3000 coronary arteries and aortas—the aorta is our largest artery—from victims of traffic accidents, murder, and suicide between the ages of 15 and 34, and found so-called fatty streaks (foam cells) even in teenagers, which can turn into atherosclerotic plaques once you’re over 20, and in those over 30 they get worse before they slowly kill you. How many teenagers are we talking about here? All of them. In 100 percent of the teenage victims, foam cells had formed in their arteries. Everyone was in the first disease stage, and in 55 to 65 percent of those in their early 30s, these foam cells had already grown into atherosclerotic deposits. It sends a chill down your spine when you realize that most people in their early 30s already have plaques in their arteries. In other words, if you’re American, you’re probably heart-sick—whether you know it or not. The researchers concluded with the remark: “Atherosclerosis begins in youth.”
Imagine you had diabetes: Would you wait until you were blind before starting treatment? With heart disease, you can’t just wait until the first symptoms appear, because the first symptom can also be the last. For the majority of Americans who die of heart disease, the first symptom is “sudden cardiac death.”
An ounce of prevention is worth a pound of cure, because you can’t cure the dead.
How do you prevent atherosclerotic heart disease? By lowering your LDL cholesterol, with a diet low in saturated fat and cholesterol—one in which meat, industrial junk, dairy products, and eggs are eaten only very sparingly. “Isn’t such a radical proposal completely impractical?” an article in the Journal of the American Heart Association asked. It would require “radical commitment,” it said, but the authors pointed to the triumph of public health in driving smoking rates and lung cancer deaths down so drastically to show that anything is possible.
What evidence do we have that lifelong low LDL prevents heart disease? There is a mutation of a gene called PCSK9 that about every 50th African American can be happy about, because you’re born with it and have cholesterol levels about 40 percent lower for your entire life. As a result, they have sensationally low rates of coronary heart disease, because their risk is a whopping 88 percent lower—even though they are otherwise threatened by risks. Most people with this mutation already had high blood pressure, were overweight, smoked, or had diabetes, but all of that only shows that a lifelong low LDL cholesterol level significantly lowers the risk of coronary heart disease, even when many other risk factors are present.
This drop of almost 90 percent in cardiac events such as a heart attack or sudden cardiac death occurred at an average LDL of 100 milligrams/deciliter; by comparison, those without the mutation had 138 milligrams/deciliter. With medication or through diet, you could very easily achieve an even lower LDL. But wait. Why does an LDL cholesterol lowered by 40 milligrams/deciliter in the lucky people with the mutation reduce the incidence of coronary heart disease by almost 90 percent, while the same drop of 40 points from a statin drug reduces the prevalence of coronary heart disease by only 20 percent? The answer is very likely duration. The longer arteries are exposed to a higher LDL level in the blood, the more cholesterol can deposit on the arterial wall and inflame it.
Just as you determine smoking dose in pack-years by multiplying the number of cigarettes smoked per day by the number of years, an editorial in the Journal of the American College of Cardiology proposed the concept of cholesterol-years, which capture the full extent of how long our arteries have been bathing in cholesterol. That explains why the indigenous Tsimane, the Bolivian farmers, have virtually no coronary heart disease even though their average LDL isn’t below 90. An 80-year-old Tsimane appears to have the “vascular age” of an American in their mid-50s. When it comes to lowering LDL cholesterol, it’s not just about how low the level is, but also how long it stays that low—and the longer and lower, the better.