Lowering Cholesterol: Hacking “YMMV”
May 10, 2020 2:15 AM   Subscribe

YANMD but you have a good ratio of knowledge to opinion on this topic. How does one start to sort through the profusion of information about cholesterol levels and heart disease and diet and statins, especially when it’s so contradictory?

Some swear by a vegetarian diet, some by a paleo diet, etc., etc. How do I figure out which diet is optimal for me? Secondarily, how much can physical activity realistically change one’s score, or being a “normal” weight?

This is the point where some people chime in with some version of YMMV. Well, of course it does. Is there really no way to get a read on which path (mostly in terms of diet) is likely to be best for a given individual?

If there’s no help for it but to follow a certain diet and monitor the results, how long to does one have to eat said diet before testing? What words can I use to help my doctor have patience with trying various alternatives and testing when they’ve been urging statin use for a while now. Only in the past few months have I made any positive changes (thanks to the damn pandemic, but hey, silver lining).

N=1 anecdotes may be interesting, but not so much helpful, unless you have a robust way to determine if we’re in the same "tribe" when it comes to this matter.
posted by dancing leaves to Health & Fitness (14 answers total) 10 users marked this as a favorite
The words I used were, "I'm not going to take a statin, I will work on this."
posted by InkaLomax at 3:22 AM on May 10 [5 favorites]

>or being a “normal” weight?

It *can* influence you levels bigly, and most docs/cardiologists will recommend overweight people with elevated levels focus on losing weight. this is not a controversial idea. You said you didn want anecdata, but my own levels are closely linked to my weight. However,

>What words can I use to help my doctor have patience with trying various alternatives...they’ve been urging statin use for a while now

Why are you so sure you shouldn't be on meds? Maybe you really do need them, a least until you get you weight under control. I have consistently very high "bad" cholesterol and nobody's *ever* urged statin use because of my low risk profile (premenopausal woman, very good HDL). Maybe your risk profile is less good and you don't have 6, 9, 12 months to spare to wait and see what effect weight loss will have .
posted by shaademaan at 4:29 AM on May 10 [1 favorite]

When my doctor wanted me to take blood pressure medication, and I wanted to work on my diet, I just said I wasn't going to take medication. I have gotten really good at just telling doctors no though. I got my blood pressure down with a vegan diet. Since I'm vegan, I don't eat anything with dietary cholesterol, and my cholesterol is now so low (total 114) that online heart attack risk calculators will not accept the number.

While it's true that there may be some variation in blood tests in individuals, only very low fat, vegan or vegetarian diets have been shown in controlled studies to reverse actual disease - as in plaque in the arteries lessens. This was shown in studies by Dean Ornish and Caldwell Esselstyn (though Esselsyn did not have a control group). Ornish's original study included low fat dairy and egg whites, so it was not vegan. However, both doctors do not permit added oil in their diets. They did not show any people who followed the diet and had their cholesterol not go down. As far as I know, there are no studies of a paleo or Atkins diet that look at plaque in the arteries and not just biomarkers, so I would say we don't know if some people actually do better on a paleo diet.

John McDougall runs a ten-day program having patients follow a very, low-fat vegan diet. He published a study showing drops in cholesterol ranging from 22 to 39 points in seven days. There are ten-day immersion programs all over the country (Whole Foods sends employees to these), and people have significant changes in that time period. If you are willing to be strict, changes can happen very quickly.

There can be issues with studies. For instance, there have been some studies purporting to show that a low-fat diet doesn't work. However, they end up defining low fat as 30% fat, which is pretty close to the standard American diet. Diets that reverse heart disease and substantially lower cholesterol are about 10% fat. It is not easy to get people to follow those diets long term, since they are so different from what people normally eat. But I can tell you from personal experience it is possible if you are motivated enough.

Now someone is going to pop in and say that eggs don't raise cholesterol, but the studies that show that (funded by the egg industry) use diets that are otherwise high in cholesterol. If your diet is already high in cholesterol, a few eggs won't raise it much.

My pet peeve is people who say this diet is easy to follow. It's not. It's very different from how most people eat (especially eliminating oil - it took me ages to figure out how to saute onions without oil). Change is hard. In my experience, it's been extremely worthwhile though. In addition to now having low cholesterol and normal blood pressure, I lost 65 pounds, and my GERD and adult acne both went away. (Unfortunately, I then got cancer - I blame years of a very bad diet.) The movie Forks Over Knives is very inspirational. I think it's still available on Netflix. I'm less fond of Game Changers, since it implies that there's something magic about a vegan diet, even if it includes lots of junk food. That's not true. If you want to improve your health, you need to eat natural, unprocessed foods as much as possible.

I hope this answers your question. If you are interested in trying this and want more info, MeMail me and I can point you to many resources. I would suggest Esselstyn's book Prevent and Reverse Heart Disease.
posted by FencingGal at 4:43 AM on May 10 [4 favorites]

I've been "normal weight" all along but my total cholesterol has been high a couple of times in recent annual physicals. I'm a 70 yr old woman. My solution has been to go semi-vegan: I eat a mostly plant-based diet, but use skim cow milk in cereal and coffee, I eat some lower-fat cheese, and very occasionally some meat. No eggs, and sadly, no bacon. I've brought my total cholesterol down more than 50 points. I also walk 3 miles a day. So yeah, normal weight, good eating, daily exercise.

My sister is an MD, she says it's really the ratio that counts the most, not the individual numbers. I can't remember right now exactly what the ratio refers to but mine has always been good and now it's even better. My good cholesterol is excellent.

I'm sure some of it is genetic.

Feel free to memail me.
posted by mareli at 4:45 AM on May 10

For most (but not all) people dietary cholesterol has little relationship to blood cholesterol numbers. Your body is capable of creating all the cholesterol it needs to transport excess sugar and fats that the liver processes out to the body. There is little consensus on macronutrients (fat vs carbs vs protein) other than simple carbs seem evil. Big studies have generally not found any one diet to be spectacularly effective, thought mostly because people don't stick to them. The right diet is one that you can stick to. It often helps if the diet has an ethos that makes it mentally consistent. Some sacrifices are inevitable, and no diets that work are really easy for most people.

I think 3-4 months is a good time to see the effects that diet will have on labs. Exercise and diet can hugely affect labs. Unless you have already had a heart attack or stroke, the effects of cholesterol are usually measured over decades. If you are making genuine effort and tracking progress in fitness and weight, then a couple of tests over a year to work out what will fit with you isn't a big deal.

The doctor pushes because most people leave the office and go back to whatever they were doing with little to no change. Not everyone that makes an honest effort will succeed. A statin certainly isn't a mark of shame.
posted by a robot made out of meat at 6:36 AM on May 10 [2 favorites]

Here's a scientific review article.

Review articles look at, evaluate, and synthesize a multitude of research articles.
posted by mareli at 7:12 AM on May 10

Hi there, I've been part of one of the research groups that's looked at this systematically (happy to discuss that via email). Nutshell: FencingGal's comment covers the most broadly supported dietary approach to lowering cholesterol. The Esselstyns have been promoting their "Engine 2" cookbook etc. based on these studies, and that cookbook is very easy/basic—its not a cookbook for making elegant, Michelin starred dishes, it's for feeding yourself in a healthful way. Yes, it's an adjustment for many learning to omit or heavily restrict refined fats and oils but, as these studies support, a dietary and lifestyle intervention is much less severe than resigning oneself to permanently relying on pharmaceutical/surgical interventions.
posted by late afternoon dreaming hotel at 7:24 AM on May 10 [2 favorites]

Yeah, I think it is YMMV because people can respond differently to different diets, and some diets are easier for people to follow than others. Last time I was at the Dr they were touting the plant based diet, I did vegan instead because I like oil and have vegan friends - so it was a lifestyle choice more than anything. I don't see you mention exercise, but my understanding of the research is that exercise is key.

I'll also add that after I plateaued the Dr recommended red yeast rice which I was pretty skeptical of, but has some research behind it as well. Quite opposite from your doctor, she was pretty against me going on prescribed statins, so would be worth exploring why your doctor is pushing it? Not to say they are wrong, but rather if you are in a serious risk group, you should be told.
posted by Toddles at 7:50 AM on May 10

I just have to point out here that the fairly extreme diets promoted by Esselstyn and especially McDougall have a lot of skeptics and detractors among mainstream physicians and the American Heart association. I mean McDougall advises people to eat potatoes only for the first week of the diet.
posted by shaademaan at 7:52 AM on May 10 [1 favorite]

I pushed against statins as well, but relented after a Berkeley Heart Lab test (https://www.southdenver.com/wp-content/uploads/2012/09/Berkeley-2-New-for-web.pdf). The results indicated a genetic condition that cannot be fully remedied with diet/exercise, and is resistant to alternatives like red rice yeast.
I started out with a fairly high dose (20mcg) but we kept testing and I’m down to 5mcg with great numbers. Not everyone can get results from non-medicated tactics.
posted by dbmcd at 8:33 AM on May 10 [3 favorites]

Trying to lower your blood cholesterol with diet is a good idea because if nothing else it will help zero in on whether or not something else is going on, like familial hypercholesterolemia. I would explain that your doctor and see how they respond.
posted by Automocar at 8:57 AM on May 10 [1 favorite]

The words I used were, "I'm not going to take a statin, I will work on this."

This is me with my doc. I have cholesterol that appears to be on the high side genetically. He has to keep asking because that's good doctoring. At one point, just to see, I went all-vegan (and upped fiber, walnuts, garlic, etc) and noticed a difference within a few months. I tried red rice yeast, did not notice a difference. I also exercise for over 45 minutes most days of the week. Mayo Clinic's list of "things to try" is pretty straightforward and good.
posted by jessamyn at 9:50 AM on May 10 [1 favorite]

FYI, red yeast rice works because it contains a chemical that is identical to statins- but in a less regulated, less consistent format. It’s like getting penicillin by growing and eating your own mold.
posted by MadamM at 12:40 PM on May 10 [1 favorite]

I lowered my cholesterol from unhealthy to low. Not sure how long it took because I didn't check it for a year and a half. I went vegan for a few months, then no-oil, very low-fat vegetarian for that year. I also lost 20 lbs and worked out lifting weights 4-5 days a week.

I ate eggs, but only a yolk on rare occasions. Mostly egg whites. Nonfat Greek yogurt, whey shakes and very small amounts of cheese on rare occasions. The times I ate baked goods I didn't ask what was in it. But I wasn't "cheating" on a weekly basis is what I'm saying. I also inadvertently went high fiber which also affects cholesterol. I was tracking calories the whole time with cronometer and I regularly got 130% and sometimes 200% of the RDA for fiber. Lots of whole grains, whole grain pasta, brown rice, and greens every day. I'd frequently have a fruit smoothie with two cups of greens. I stopped using sugar and switched to xylitol and stevia for my kicks.

Esseltyn's advice is solid but god in heaven they can't cook. I'd slit my own throat if I were eating like that. Don't think you have to eat poorly prepared food to follow their advice. If you want a cookbook, I can recommend Somer Mccowan's "The Abundance Diet". A decent blog is https://blog.fatfreevegan.com/.

Your diet doesn't have to be 100%, but a majority, if you want to control it that way. And I would recommend going completely no-oil vegan for a month or two and then checking your numbers again to have confidence you're going in the right direction.

Good luck. It's certainly doable if it's what you want.
posted by liminal_shadows at 4:27 PM on May 10

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