Humans have a natural tendency throughout their history (from the Stone Age to exponential technologies) to oversimplify complex environments, and as a result they do not evaluate all risks in the best way (or some at all). The reasons for their actions are very complex, and I don’t want to go into all their forms in this series of blogs. However, I do want to address here one specific pattern of decision making and risk assessment that people are fond of (also) in the medical and dietary fields.
So what is the mythical problem? It is the matching of unknown inputs to known outputs, or in other words – confusing causality with correlation. Nassim Nicholas Taleb described this phenomenon very nicely in his book The Black Swan and called it the “narrative fallacy”, or translated as “the fallacy of narrative”. The narrative fallacy describes the tendency of a person to invent a story (input) that illusorily justifies the existence of a phenomenon (output), with the result that the person himself thinks that he understands the phenomenon well enough.
An observant individual has surely caught another individual afflicted with the narrative fallacy at least once in his or her lifetime. Whether it was when he saw an angry gentleman at a bus stop shouting that the cause of his bad financial situation was solely due to such and such a politician, or when a despondent lady at the physiotherapist’s complained that her bulging intervertebral discs were the result of genetics.
However, since this blog series is about nutrition, I’m going to relate the fallacy of narrative exclusively in the context of food.
In the series “Medicine under the guise of dietary narrative”, I want to cover four of the most essential nutrients that I believe are highly misperceived in our civilization, and as a result, many of them are wrongly damned, adored, or ignored, or dosed incorrectly. Or a little of everything.
This part (1) is just about cholesterol.
The doctor says cholesterol is yuck
Everyone of us has certainly encountered the criticism of cholesterol. Whether it was in primary school, where the teacher was saying something about how cholesterol is crap and how it causes cardiac arrests, or in an outpatient clinic with a man writing with the label ‘Mr Doctor’ who wants to prescribe statins immediately for high cholesterol and lecturing his patients about limiting fatty foods because he has succumbed to the narrative fallacy and considers them to be the cause of health problems. To top it all off, there are even those “Mr. Doctors” who dismiss saturated fatty acids for high cholesterol and recommend replacement therapy with poisons such as sunflower or rapeseed oil to their desperate patients.
OK, so now let’s explain how cholesterol really is.
The main cause of blood vessel damage is not cholesterol — it is oxidized cholesterol. Small LDL cholesterol molecules oxidize easily and cause inflammation, which increases the risk of cardiovascular disease.
For those who don’t know what LDL actually is, I remind them of the still socially (and especially medically!) widely held view of cholesterol, which is as follows:
HDL cholesterol is yum yum, LDL cholesterol is yuck yuck. If yuck yuck LDL is high, drugs (statins) need to be put on to lower it, otherwise there is a risk of heart attack or other ailments.
The origins of this medical bullshit can be traced back to the late 1950s, when the physiologist Acel Keys sort of cherry-picked results from epidemiological studies that he found useful to confirm his hypothesis about the harmfulness of cholesterol and saturated fat in the diet.
His so-called “seven-country study” was explicitly steeped in the narrative fallacy, but I don’t want to go into that in this article. The bottom line is that Mr Keys managed to convince several very important organisations of his truth, and as a result the whole world began to fight back against fats and cholesterol.
So let’s take a look at why cholesterol is cool, though, and why high-cholesterol foods are healthy.
Why to eat fatty foods?
The human liver is able to produce cholesterol no matter how much cholesterol a person ingests in their diet. The total amount of cholesterol consumed actually has no effect on blood cholesterol levels, unless you happen to be in the cholesterol-sensitive group of people, which is about 30% of the population.
But even if you are one of them, you have nothing to worry about. While high-cholesterol foods do raise the absolute value of cholesterol in the blood, they lower the levels of bad, small LDL and raise the levels of large LDL and HDL. This basically means that they reduce the risk of cardiovascular disease.
(It’s not entirely true that dietary fats don’t affect blood cholesterol levels at all, but unless you have an adverse genetic mutation — for example, in the gene for the LDL receptor that causes familial hypercholesterolaemia — it’s more likely that the other factors will be to blame for high cholesterol. And I want to cover these in the next section “Triglycerides — a source of energy”)
But there is another very good reason to eat high-cholesterol foods. And it is none other than choline.
Choline is a B vitamin that has a variety of uses in the body. A choline deficiency can have a very bad impact on human health – causing fatigue, insomnia, poor kidney function, memory problems, poor red blood cell production, infertility, cancer, and much more.
The best sources of choline are egg yolks and liver. Other good sources include pork, cod, Brussels sprouts and broccoli.
But what’s all the cholesterol for?
25% of all cholesterol is in the human brain. Cholesterol is its essential component, without which it would not function properly. If that’s not good enough reason for you, cholesterol:
- Is important in the formation of nerve synapses — memory disorders, dementia, Parkinson’s and Alzheimer’s disease can undoubtedly be linked to cholesterol deficiency.
- It plays an important role in cell-to-cell interactions and is also a precursor of bile acids. Without these acids, man would not be able to digest fats and his digestion would therefore function very poorly.
- It is necessary for the production of sex hormones. No cholesterol means no testosterone. And testosterone isn’t just a hormone for those who want to be muscle guys — it’s one of the most important hormones for body building, motivation, and overall health. And that applies to women, too, of course.
- Cholesterol is a precursor for the production of vitamin D, which is needed for healthy bones and nervous system, muscle tone, insulin production, and immune system function.
Triglycerides — a source of energy
As promised, in this section I will discuss the causes of high cholesterol. The key to everything is triglycerides.
Triglycerides (TAGs) make up about 95% of all fats in the human body. They are the primary source of energy for many of our bodies’ tissues. The heart likes them so much that it even prefers them to glucose. They are crucial for the transport and absorption of fat-soluble vitamins.
Our body stores supplies in the form of triglycerides.
Humans can also make triglycerides from carbohydrates (glucose) and some amino acids. This is a very important fact, which implies that elevated triglyceride levels can also be caused by increased intake of carbohydrate foods.
So how does this work in the body?
When you eat a carbohydrate-containing food, it (mostly) breaks down into glucose. Then, as the liver replenishes its glycogen stores (the storage form of glucose) from it, it distributes it to the body through the blood. The glucose begins to circulate through the bloodstream looking for those cells that want to eat it up.
If you’ve been moving recently, or are very over-motivated and are moving even as you read this, most of the glucose is being absorbed by your muscles. However, if you have full glycogen stores (which most people do most of the time these days), your glucose is going back to your liver and being converted into fat in the form of triglycerides.
Worse yet, that fructose is not used by your muscles in any way, and what is not used by the liver is converted directly into fat (triglycerides).
Well, and what’s absolutely horrible, so glucose molecules are pretty cheap sluts. As they, along with insulin (which releases them into the cells), search for cells that might want to eat them up, they offer themselves up to all the cells around them. And if the surrounding cells have had enough, they’ll lower their sensitivity to insulin. Consequently, the new glucose will be much harder to get into the cells, and so more and more of it will be converted to fat.
Another important point is that insulin reduces fat burning to a large extent. And the liver happily pumps it into the blood.
Since most cells in its presence prefer glucose to fat, our body cleans up the excess fat into fat cells, which take it in without any problem. And one can thus fatten up merrily, even if one does not take in any fat in the diet.
And the aesthetics of the fat stores is, of course, not the biggest problem.
In order to understand what cholesterol actually is, it remains to explain in detail what HDL, LDL and other lipoproteins are.
If you poured ghee into your coffee this morning, as I did, it’s probably clear to you that fat and water separate quite nicely.
Human blood is mostly water, and that’s why a mechanism for transporting fats in an aqueous environment is necessary for the body to function properly.
It is this function that is fulfilled by the so-called lipoproteins (which are largely composed of phospholipids) that distribute cholesterol and triglycerides throughout the body. If you don’t know what phospholipids are, no stress. In simple terms, think of lipoproteins as a kind of sphere that is hydrophobic on the outside (repels water) and lipophobic on the inside (repels fat).
There are several groups of lipoproteins:
- high-density lipoproteins (HDL)
- intermediate density lipoproteins (IDL)
- low density lipoproteins (LDL)
- very low density lipoproteins (VLDL)
Within several of these groups there are also many types of lipoproteins; so-called subfractions. And here lies one of the main points of misdiagnosis of cardiovascular disease risk based on elevated LDL cholesterol.
LDL, whose role is to shutt cholesterol from the liver to the cells, has up to 7 (currently known) subfractions. Of these, 2 are probably harmless and the remaining 5 are harmful (atherogenic).
HDL, whose main role is to collect fats around the body and transport them back to the liver, also has several subfractions. HDL virtually “cleans up” after LDL and is therefore universally attributed an atheroprotective function (it protects our blood vessels).
LDL doesn’t (always) want to kill you!
Unfortunately, most people with college degrees completely ignore the fact that there are several types of LDL cholesterol and take it as a whole. In doing so, elevated total LDL cholesterol may not be a problem at all. In fact, in some studies, elevated LDL cholesterol in the elderly has been linked to better brain function.
Although there are up to 7 subfractions of LDL, in terms of their harmfulness to our bodies, we could simplify them by dividing them into 2 units, or types — small and dense (dense) particles (sd-LDL) and large, sparse particles.
If you eat a lot of good quality saturated fat and your LDL cholesterol has increased, it is most likely to be large LDL particles. These particles spend an average of 2 days in your bloodstream and are harmless.
However, if you are eating more carbohydrates than you should and have high levels of inflammation, then it is very likely that the small particles are more likely to be responsible for your elevated LDL levels. These persist in circulation for up to 5 days, penetrate the walls of blood vessels and are dangerous.
These small LDL particles are actually important in the short term for repairing a disrupted intestinal wall, and so their high levels are a consequence of increased inflammation and glycation, not the cause of it.
The real problem with LDL
So LDL per se is not bad, because it is needed to distribute cholesterol around the body, without which a person would not survive for long. However, the smaller the LDL particle, the more dangerous it is.
But how does it work in the body?
Small, denser LDL particles can more easily penetrate the blood vessel lining (endothelium) and stay stuck there. There they cause deposits that can form clots over time (through the action of inflammation). These can break loose from the endothelium, make their way through the bloodstream and clog the blood vessels of major organs such as the heart (output = heart attack) and the brain (output = stroke).
Small LDL particles are also less easily recognised by LDL receptor cells, causing them to keep their cholesterol to themselves and stay in the bloodstream longer than they should. If they travel through the bloodstream for a long time, both the lipoproteins and the cholesterol themselves undergo various forms of damage (oxidation and glycation).
As I mentioned in the introduction of the blog, cholesterol oxidation is dangerous. Oxidation occurs when LDL particles come into contact with free radicals. The amount of free radicals in the human body is negatively affected mainly by smoking and the intake of trans-saturated fats and other toxins from food and the environment.
Dietary cholesterol oxidizes when exposed to heat and oxygen. This is why, for example, scrambled eggs are the absolute worst way to prepare eggs.
Oxidised LDL also gets trapped in the walls of blood vessels. The LDL particles thus spoiled are then absorbed by macrophages (immune cells). If a macrophage is eaten up by LDL particles, it becomes a ‘foam cell’. A foam cell also very easily ‘sticks’ to the walls of blood vessels and forms deposits.
So it is a problem if small LDL particles predominate over large ones in your blood under any circumstances. This can only be detected by special tests that can distinguish between different sub-fractions of LDL particles. If you want to pay for one, feel free — in Slovakia, such tests are offered by e.g. Alpha Medical for less than 20 euros.
What do statins do?
What are statins? Statins are the crap your doctor will probably suggest you take the moment he or she measures your high cholesterol. However, the chances that you don’t actually need these drugs and that they will do more harm than good are too high.
There is no evidence that statins reduce the risk of cardiovascular disease any more than other, cheaper and less dangerous measures. These mainly include diet change, exercise and stress management. Most importantly, all of the above measures address a complex cause and do not just block the possible consequences of something that is identified as a problem by a person with a college degree.
Statins ultimately boast two main effects:
- They lower LDL cholesterol, which can be both beneficial and detrimental. As I mentioned earlier, LDL is essential in the body.
- They reduce inflammation; which can also be great, but can be achieved in a more comprehensive and effective way without side effects.
It is the side effects of statins that are something that these drugs are very well known for. And there are not a few of them at all.
About one-third of people who take them experience some limitations in some area of their lives. These are mostly muscle pain (sometimes muscle breakdown), nausea, fatigue, and in some cases liver damage or the development of type 2 diabetes. Diabetes, by the way, is probably the absolute worst thing for the health of the blood vessels – much worse than the increased presence of small LDL cholesterol molecules.
Statins are also referred to by many people as mitochondrial poison. If you know anything about mitochondria, it’s clear that you should worship them. Take care of them so that they are well and producing energy. The less healthy your mitochondria are, the less alive you are.
But most importantly, statins are some of the most profitable drugs in the world and their sales are in the nice billions of dollars.