Chapter 6: Fat and Cholesterol Are Not Your Enemy

Question 1

What is Cholesterol?

Answer 1

Cholesterol is a yellow, waxy molecule comprised of lipid (fat).

Question 2

What are lipoproteins composed of?

Answer 2

Lipoproteins are comprised of cholesterol, triglyceride, phospholipid (another type of fat), and protein.

Question 3

Where is cholesterol manufactured?

Answer 3

In the liver

Question 4

True or False
Cholesterol and other fats in the bloodstream are packaged together with lipoproteins to ease their movement through the bloodstream.

Answer 4

True

Question 5

True or False

The liver provides for the body’s cholesterol needs regardless of how much you eat.

Answer 5

True
The liver varies its production level in accordance with dietary intake. The less cholesterol you ingest, the more the liver will make.

Question 6

Why must cholesterol be packaged together with lipoproteins in the blood?

Answer 6

Cholesterol is oil-based and the bloodstream is water-based.

Question 7

True or False
Most cells in the body can manufacture the cholesterol they need because the LDL particles in the blood will direct the production of more cholesterol.

Answer 7

False
Protein molecules in the cell will direct the production of more cholesterol (or pulling in more LDL particles circulating in the bloodstream) if insufficient levels are detected in the cell.

Question 8

Name the types of lipoproteins from largest to smallest.

Answer 8

1. Chylomicrons,
2. VLDLs (Very Low Density Lipoprotein)
3. IDLs,
4. LDLs, (Low Density Lipoprotein) and
5. HDLs (High-Density Lipoprotein)
   as well as subfractions of each).

Question 9

True or False

The three most prominent lipoproteins relative to the heart disease discussion are HDLs, LDLs and IDLs.

Answer 9

False
The three that are the most prominent in the heart disease saga are VLDLs, LDLs, and HDLs (very low-density, low-density, and high-density lipoproteins, respectively).

Question 10

Why are HDLs known as “nature’s garbage trucks?”

Answer 10

HDLs are known as the “good cholesterol” or “nature’s garbage trucks” for their ability to cleanse the arteries and bloodstream of oxidized cholesterol, thereby reducing the risk of heart disease.

HDLs (High-density lipoproteins): HDLs take oxidized cholesterol from the bloodstream back to the liver for excretion or recycling into useful service.

Question 11

Where do HDLs take oxidized cholesterol after removing it from the bloodstream?

Answer 11

To the liver for excretion or recycling.

Question 12

True or False

About 30 percent of the total cholesterol in a healthy body is composed of HDL.

Answer 12

True

Question 13

True or False

Cholesterol is contained in the membrane of every cell in the body except blood plasma.

Answer 13

False

Cholesterol is contained in the membrane of every cell in the body, as well as in blood plasma.

Question 14

What roles do cholesterol play in the body?

Answer 14

Building and maintaining cell membranes, metabolizing fat-soluble vitamins, producing bile to help digest fat, and synthesizing many hormones, including sex hormones.

Question 15

True or False

High levels of HDL decrease the risk of heart disease.

Answer 15

True

Question 16

What does VLDL stand for?

Answer 16

Very Low-Density Lipoproteins

Question 17

Where are VLDLs manufactured?

Answer 17

In the liver

Question 18

What is the primary function of VLDL?

Answer 18

VLDL transports triglyceride and cholesterol to target fat or muscle cells.

Question 19

True or False
Prior to delivering their payload to the cells, VLDLs are composed of about 80 percent cholesterol and 20 percent triglyceride.

Answer 19

False
Initially, VLDLs are composed of about 80 percent triglyceride. After VLDLs deliver their cargo to various target cells in the body, they contain mostly cholesterol and minimal triglyceride.

Question 20

What takes place after VLDLs deliver their contents to the cells?

Answer 20

They shrink substantially in size and transform into either large, fluffy LDLs or small, dense LDLs.

Question 21

What is another name for large, fluffy LDL?

Answer 21

Buoyant LDL

Question 22

How is large, fluffy LDL formed?

Answer 22

This type of cholesterol is formed from VLDL when blood levels of triglycerides and insulin are low.

Question 23

True or False

In all cases, the presence of high concentrations of large, fluffy LDL is a prominent indicator of heart disease risk.

Answer 23

False
These molecules are generally harmless except in the presence of other risk factors (high insulin-producing diet, systemic inflammation, abdominal obesity, family history, smoking, etc.).

Question 24

What factors can contribute to large, fluffy LDL becoming oxidized?

Answer 24

Adverse lifestyle practices, low HDL values, poor thyroid function.

Question 25

How can the thyroid contribute to oxidation of large, fluffy LDL?

Answer 25

Poor thyroid function down-regulates LDL receptors and causes LDL to circulate for longer periods in the bloodstream with insufficient antioxidant protection.

Question 26

What is familial hypercholesterolemia?

Answer 26

A genetic condition in which LDL values are extremely high, and almost entirely of the large, fluffy variety.

Question 27

What is VLDL?

Answer 27

Small, dense LDL

Question 28

How is VLDL created?

Answer 28

VLDL converts to small, dense LDL when triglyceride and insulin levels are elevated in the bloodstream.

Question 29

What is the endothelial cell layer (ECL)?

Answer 29

The cells that line the walls of your arteries.

Question 30

What happens when VLDL gets lodged in the ECL?

Answer 30

Since oxygen is constantly flowing through arteries, the small, dense LDL that end up trapped in the ECL sustain oxidative damage and trigger an immune response that can progress toward an eventual heart attack.

Question 31

Other than high-carb eating, what is another pathway to the accumulation of small, dense LDL?

Answer 31

Some who convert to Primal/paleo eating develop sluggish thyroid function which triggers an elevation in small, dense LDL because LDL is being cleared from the blood slower than usual. Often this unique population of thyroid sufferers can tweak their eating habits (e.g., adding back more high-nutrient value carbs), and regain optimal thyroid function and clearance of oxidized cholesterol.

Question 32

True or False

Having a relatively low total LDL reading does not guarantee a person won’t have a heart attack.

Answer 32

True
Heart attacks can and do occur in individuals who have a relatively low total, and seemingly safe, LDL reading if a high percentage of the total LDL is small, dense LDL, and if systemic inflammation and oxidative damage are present due to adverse diet and lifestyle practices.

Question 33

True or False
The total LDL reading on a blood test indicates both the total cholesterol amount carried by your LDL particles as well as the size of the particles.

Answer 33

False

Total LDL readings do not reveal what size the particles are.

Question 34

What is LDL-C?

Answer 34

LDL-C is the term for total amount of cholesterol someone is carrying.

Question 35

What is LDL-P?

Answer 35

LDL-P is the number of LDL particles in the blood.

Question 36

Why is LDL-C not always a reliable measure of the amount of LDL someone’s blood contains?

Answer 36

Although LDL-C is often used to estimate the amount of LDL someone’s blood contains (with the logic that having more “passengers” to transport will usually mean there are more “vehicles” zooming to and fro), it can be misleading when we take particle size into account.

Question 37

True or False
Eating Primally (a diet high in natural saturated fats) can result in an increase in the number of LDL particles in the bloodstream.

Answer 37

False
Eating Primally might increase the total amount of cholesterol in the bloodstream, but typically in the form of large, fluffy LDL (buses).

Question 38

True or False
Dr. Ronesh Sinha recommends that, due to evidence which shows that an ideal LDL level of 100 is not fully protective against heart attacks, LDL targets should be set even lower.

Answer 38

False
Dr. Ronesh Sinha references a UCLA meta-study (analysis of many independent studies) showing that 75 percent of patients hospitalized for a heart attack had an LDL of less than 130 mg/dl (widely accepted as “safe”), and that half of the victims had an LDL under 100, widely considered “ideal.” Unfortunately, as Dr. Sinha explains, instead of seeing the big picture of how all risk factors interplay, “many physicians and drug companies are [mis]-interpreting the results of the UCLA meta-study to mean we should set our LDL targets even lower.”

Question 39

Summarize the heart disease process.

Answer 39

Small, dense LDL cholesterol molecules hang out in the bloodstream for far too long, and are oxidized due to the constant flow of hemoglobin and exposure to free radicals and other oxidants. These oxidized LDL molecules then lodge onto damaged (and thus more receptive) ECL, only to become oxidized even further. Inflammation is caused by the immune response of the macrophages turning into foam cells. Coagulation (clot formation) eventually causes a significant obstruction—a fat-filled tumor known commonly as “plaque”—on the ECL.

Question 40

True or False
In a healthy body, cholesterol molecules can serve as a temporary band-aid to cover lesions in the ECL, and are then recycled back to the liver by HDL when the inflammation subsides.

Answer 40

True

Question 41

True or False
Atherosclerosis is characterized by plaques that are formed in arteries when small, dense LDL molecules become lodged in the ECL and cause inflammation when they become oxidized by the constant flow of oxygenated blood passing by.

Answer 41

True

Question 42

What are macrophages?

Answer 42

Scavenging white blood cells designed to engulf and digest cellular debris that rush to the scene and attempt to gobble up oxidized small, dense LDL.

Question 43

What are foam cells?

Answer 43

When macrophages become overwhelmed by the effort to gobble up oxidized small, dense LDL, they expand in size to become what are known as foam cells.

Question 44

How do foam cells lead to additional inflammation and oxidation?

Answer 44

Foam cells produce a chemical called myeloperoxidase, which further oxidizes LDL particles. Foam cells also release chemicals called cytokines into the bloodstream, which attract more macrophages to the area to cause further inflammatory damage.

Question 45

How do plaques cause stroke or heart attack?

Answer 45

As oxidation and inflammation continue, plaques becomes stiff and calcified and more susceptible to rupture. Once a rupture occurs, it can block the artery on the spot, or more commonly detach from the wall, drift into circulation and eventually cause a stroke, or a heart attack (aka myocardial infarction—blockage of a coronary artery).

Question 46

What is a stroke?

Answer 46

blockage of an artery heading to the brain

Question 47

What is a myocardial infarction?

Answer 47

aka “heart attack, Myocardial infarction is the blockage of a coronary artery (feeding the heart itself)

Question 48

What is hyperinsulinemia?

Answer 48

Chronically elevated insulin levels leads to a condition known as hyperinsulinemia, which promotes systemic inflammation in the body.

Question 49

How does hyperinsulinemia lead to high blood pressure?

Answer 49

It causes damage to the ECL by reducing bioavailability of nitric oxide (a compound that keeps the ECL relaxed) and promoting platelet adhesiveness (sticky platelets that clot more readily). These conditions increase the sheer force of blood flowing against the ECL (high blood pressure).

Question 50

How do elevated insulin levels affect triglycerides?

Answer 50

Chronically elevated insulin levels prevent triglyceride from being mobilized into free fatty acids for use as energy. Instead, you are stuck in a fat storage pattern instead of a balance between energy mobilization (burning of fatty acids) and energy storage (storing ingested fats or ingested carbs converted into fats).

Question 51

What effect do elevated levels of trigyceride in the bloodstream have on VLDL?

Answer 51

Elevated levels of triglyceride in the bloodstream drive VLDL conversion into small, dense LDL instead of large, fluffy LDL.

Question 52

What factors can contribute to elevated cortisol levels?

Answer 52

Poor eating habits, chronic exercise habits, insufficient sleep, and other forms of life stress that overstimulate the fight-or-flight response can result in chronic, or systemic, inflammation.

Question 53

What is cortisol?

Answer 53

Stress hormone

Question 54

True or False

Insufficient levels of HDL can significantly increase heart disease risk.

Answer 54

True

Question 55

List elements of the Standard American Diet that can elevate disease risk.

Answer 55

Excess carb intake and insulin production;
Excess consumption of PUFA oils (which are inherently prone to oxidation and become incorporated into LDL particles);
Any consumption of chemically altered trans or partially hydrogenated fats (which impair blood flow);
Insufficient intake of antioxidants (which can help prevent oxidation in the first place);
Insufficient intake of saturated fat (eating saturated fat helps elevate HDL and makes LDL particles more resistant to oxidation);
Poor LDL clearance (with diet likely contributing to poor thyroid function that inhibits LDL clearance).

Question 56

True or False

Statins reduce risk of heart disease by targeting and reducing the levels of the most troublesome lipoproteins.

Answer 56

False

Statins reduce levels of all types of cholesterol, including HDL.

Question 57

According to Dr. Cate Shanahan, what is the most important blood metric to assess?

Answer 57

Triglyceride-to-HDL ratio. A ratio of 3.5:1 or below is desirable, while a ratio of 1:1 is considered superior.

Question 58

What factors lead to excessive triglycerides?

Answer 58

Excess carbohydrate intake, excess insulin production, and the conversion of excess ingested carbohydrates into triglycerides in the liver.

Question 59

What is the significance of high triglyceride levels?

Answer 59

High triglycerides indicate the body’s cholesterol processing system is overwhelmed.

Question 60

True or False

Elevating HDL and reducing triglycerides is the most worthwhile tandem goal to reduce heart disease risks.

Answer 60

True

Question 61

True or False

High blood pressure is not a particularly reliable indicator of unhealthy dietary, exercise and lifestyle habits.

Answer 61

False

Question 62

What is considered a safe blood pressure threshold?

Answer 62

A systolic/diastolic reading of 120/80 or lower (for each value).

Question 63

True or False

For those who are sun-challenged, supplementing can be extremely effective.

Answer 63

True

Question 64

True or False
Govermenment recommendations for dietary Vitamin D intake and sun exposure are comparable to those dispensed by Vitamin D experts.

Answer 64

False
Long-standing government recommendations for both dietary vitamin D intake (600 I.U. per day) and sun exposure are very low and in sharp contrast to the recommendations dispensed by vitamin D experts.

Question 65

What is the preferred Vitamin D blood test?

Answer 65

25(OH)D

Question 66

True or False

Vitamin D advocates recommend an optimal blood value range of 50-70 ng/mL when treating heart disease or cancer.

Answer 66

False
Vitamin D advocates agree on an optimal blood value range of 50-70 ng/mL, and a range of 70-100 ng/mL when treating heart disease or cancer.

Question 67

What level do Vitamin D experts consider to be deficient?

Answer 67

Any value below 50 ng/mL is categorized as deficient.

Question 68

What vitamin and/or mineral deficiencies could lead to excessive Vitamin D levels?

Answer 68

Vitamin A, vitamin K, and potassium

Question 69

True or False

Vegetarian sun worshippers would do well to supplement with cod liver oil.

Answer 69

True

Heavy sun exposure can deplete vitamin A, and cod liver oil boosts vitamin A levels.

Question 70

True or False

Toxicity is a danger to anyone who supplements with Vitamin D, gets too much sun exposure or eats a high Vitamin D diet.

Answer 70

False
Vitamin D toxicity is most likely to happen in unique, sensitive individuals when they take too many supplements over a long period of time. It’s impossible to become vitamin D toxic from sun exposure, since the body automatically regulates vitamin D production by tanning the skin (and consequently shutting down further vitamin D production) when you’ve had enough.

Question 71

True or False

Native Americans can likely thrive on lower ranges of Vitamin D than Caucasians.

Answer 71

True
There is believed to be some variation in optimal vitamin D levels based on ethnicity, with those of non-White ancestry able to thrive in lower ranges than light-skinned folks.

Question 72

Describe the significance of the relationship between Vitamin D levels and PTH (parathyroid hormone).

Answer 72

Vitamin D levels on the low end of normal are not problematic if you also have low levels of parathyroid hormone (PTH). PTH regulates the conversion of 25(OH)D into a more active form of vitamin D in the body. If PTH is high, above 30 pg/mL according to Dr. Masterjohn, and vitamin D is low, that suggests that there is not enough vitamin D available in the body. On the other hand, if vitamin D is borderline low (25 to 30 ng/mL), but PTH is also low, that probably reflects a functioning vitamin D regulatory system and is not cause for concern.

Question 73

True or False

Chronic overproduction of insulin can be detected on a fasting blood insulin test.

Answer 73

True

Question 74

True or False

HbA1C measures how much hemoglobin is attached to a glucose molecule.

Answer 74

False
HbA1C: Known as the “estimated average glucose” test, HbA1C measures how much glucose is attached to a hemoglobin molecule, a reliable marker for a state of elevated blood glucose levels over an extended time period.

Question 75

What does a triglyceride reading over 150 suggest?

Answer 75

An excess of oxidized LDL and thus elevated disease risk.

Question 76

What is considered to be an ideal level of trigylcerides?

Answer 76

Under 100 is optimal.

Question 77

What can be determined from a High Sensitivity C-Reactive Protein (hs-CRP) test?

Answer 77

In the absence of other acute infections, a high level of hs-CRP in your blood is a reliable sign of inflammation in the blood vessels. Elevated C-reactive protein is associated with an increased risk of heart attack, stroke, and sudden cardiac death.

Question 78

What is CRP?

Answer 78

C-Reactive Protein is C-reactive protein (CRP) is a protein that increases in the blood with inflammation and infection as well as following a heart attack, surgery, or trauma.

Question 79

True or False
Marathon runners often reveal permanently high levels of CRP as a consequence of the trauma sustained from running 26 miles.

Answer 79

False

These levels will typically return to normal in 72 hours.

Question 80

How might you determine whether someone has an elevated level of CRP without a blood test?

Answer 80

Excess belly fat is often an indicator of elevated C-reactive protein and systemic inflammation.

Question 81

What is considered an ideal level of CRP over the long term?

Answer 81

Under normal circumstances or over the long-term, ideal CRP levels are well under 1 mg/L.

Question 82

What types of cells secrete Interleukin-6?

Answer 82

T cells (a type of white blood cell that plays a huge role in the immune response) and macrophages (cells that engulf and digest—also known as phagocytosing—stray tissue and pathogens) both secrete IL-6 as part of the inflammatory response

Question 83

True or False

Homocysteine is an amino acid that can become elevated due to vitamin and mineral deficiencies.

Answer 83

True

Question 84

True or False

Elevated levels of the enzyme CPK could indicate damaged tissues from surgery.

Answer 84

True

Question 85

What is Lipoprotein(a)?

Answer 85

Lipoprotein(a) promotes coagulation (clotting), making it a heart disease risk marker. Elevated values are strongly associated with early and aggressive forms of heart disease.

Question 86

What is LpA2?

Answer 86

LpA2 is an enzyme that promotes oxidation of lipoproteins, making it a heart disease risk marker.

Question 87

True or False

Apolipoprotein B can fluctuate from day to day and should be retested at regular intervals.

Answer 87

True

Question 88

What is Apolipoprotein B?

Answer 88

A protein residing in all LDL particles. High levels indicate elevated LDL particle number and elevated heart disease risk.

Question 89

What do tests such as the Berkeley Heart Lab test, VAP test and NMR test measure?

Answer 89

LDL particle size/advanced lipid profile testing: Provides values for large, fluffy LDL (also known as “Type A LDL”) and small, dense LDL (aka, “Type B LDL”).

Question 90

What is the significance of high trigylceride levels vis a vis Type B LDL?

Answer 90

High triglyceride levels suggest that Type B values may be elevated, because blood triglyceride levels determine whether VLDL converts into large, fluffy or small, dense molecules after delivering cargo to target organs and cells.

Question 91

What does Coronary calcium testing measure?

Answer 91

Calcium buildup in the arteries via CT scan, a strong indicator of atherosclerosis.

Question 92

True or False
Prescribing statins to lower overall cholesterol levels is a medically sound course of action whenever total LDL is found to be high.

Answer 92

False
Evaluating the big picture of heart disease risk factors—as discussed with triglycerides, LDL particle sizes, HDL, systemic inflammation markers, and other advanced blood tests—is a more effective approach than the current trend of prescribing statins to millions of patients based on total cholesterol readings or total LDL cholesterol readings.

Question 93

What are the side effects of statins?

Answer 93

1. Statins suppress the production of cholesterol in the liver, producing lower blood values of all forms of lipoproteins, including beneficial HDL.
2. Suppressing cholesterol production through pharmaceutical means can interfere with healthy serotonin balance (less energy and alertness; potential mood consequences too);
3. Hampered vitamin D synthesis
4. Disturbances in regulating blood sugar,
5. Disturbances in controlling inflammation, and d
6. Disturbances in an assortment of critical hormonal processes.
7. Causes inflammation in the liver
8. Can deplete cells of CoQ-10

Question 94

What is the function of CoQ-10?

Answer 94

CoQ10 helps mitochondria produce energy in cells.

Question 95

What symptoms can deficiency of CoQ-10 cause?

Answer 95

Fatigue, muscle pain, and other indicators of muscle dysfunction. Furthermore, CoQ10 depletion can hamper the ability of all cells to fight free radicals and moderate inflammation, plus cause elevated oxidative damage in cells whose normal energy production mechanisms are compromised.

Question 96

True or False

Statins to not affect trigylceride levels or LDL particle size.

Answer 96

True

Question 97

True or False
Statins have never been shown to decrease risk of death in any women, in men under 65 or in men over 65 who have not had a heart attack.

Answer 97

False

In men OVER 65, or in men under 65 who have not had a heart attack.

Question 98

Name some of the incidental benefits, or pleiotropic effects, of statins.

Answer 98

Anti-inflammatory effect, a blood thinning effect (helping reduce plaque formation in those susceptible), and a plaque-stabilizing effect (reducing the risk of rupture in those susceptible).

Question 99

True or False
According to Dr. Sinha, only those patients who demonstrate an inability to carry out minimum levels of recommended lifestyle changes should be prescribed statins.

Answer 99

True

Question 100

With regard to the diet-heart hypothesis, what has been shown by major epidemiological studies such as Women’s Health Initiative, Health Professional’s Study, Nurses Health Study and Framingham Heart Study?

Answer 100

No correlation between dietary fat intake or cholesterol intake and heart disease.

Question 101

What are the three main reasons that dietary fat has been maligned as unhealthy?

Answer 101

Flawed science, propaganda, and manipulative marketing and advertising.

Question 102

As it relates to fat, what is the problem with the original USDA food pyramid in 1992?

Answer 102

Failure to distinguish between healthy and unhealthy fats: it is one of the most egregious examples of a blanket condemnation of dietary fat without regard to the type of fat consumed. It not only indicates to consume all forms of fat “sparingly,” but also lumps fats and oils in with sweets!

Question 103

What are some important functions of saturated fat in our bodies?

Answer 103

Saturated fat comprises about half of our cell membranes, contributes to a variety of healthy metabolic and hormonal processes in the body, is an abundant source of important vitamins like K2, A and D, and is easily burned as free fatty acids in the bloodstream.

Question 104

True or False
The fact that saturated fat and cholesterol are the agents that clog your arteries is proof that their dietary intake can be problematic.

Answer 104

False
Conventional wisdom makes an inaccurate association between saturated fat consumption and heart disease. While saturated fat and cholesterol are indeed the agents that clog your arteries and cause heart attacks and strokes, the process by which saturated fat and cholesterol turn dangerous is completely independent of their intake in the diet.

Question 105

True or False

Consuming calorically dense fatty foods rarely leads to weight gain even in the context of a high-carb diet.

Answer 105

False
Consuming calorically dense fatty foods can indeed lead to weight gain thanks to the high insulin production (from a grain-based diet) that drives ingested calories into fat storage.

Question 106

True or False

TV ownership correlates more tightly with heart diesease than saturated fat consumption.

Answer 106

True

Question 107

True or False

MyPlate rectified the long-standing bias against dietary fats in official government recommendations.

Answer 107

False

The importance of high quality dietary fats is completely absent.

Question 108

True or False

Any diet that de-emphasizes the Standard American Diet is a step in the right direction.

Answer 108

True

Question 109

What are the three main challenges to adhering to strict low-fat or vegan/vegetarian diets?

Answer 109

First, these diets exclude many rich and satisfying foods, making satiety difficult to achieve.

Second, their emphasis on carbohydrates promotes energy, appetite, and mood swings due to excess insulin production.

Third, their emphasis on grains, even whole grains, delivers less nutrient density per calorie than a Primal Blueprint type eating pattern featuring liberal intake of nutrient-dense meats, fish, fowl, eggs, vegetables, fruits, nuts, and seeds.