Serum Cholesterol: How low can you go?

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I’ve been pretty quiet for the past few weeks because I’ve been working at a hospital in NJ for my 12-week clinical internship. It’s been an enjoyable experience for the most part, mainly because the women I work with are super friendly, smart, and interested in what I have to say about alternative nutrition philosophies. I’m getting to have lots of patient interaction which has been fun, and I’ve been enjoying getting to talk to real people about nutrition. I’m generally able to have an insane amount of patient interaction, which is not typical of a clinical in-patient RD position but I figure why not practice my motivational interviewing skills while I have a captive audience?

This week, I got to spend a lot of time with patients. I did a few “heart-healthy” diet educations, focusing on the components of the diet that I believe could make a legitimate difference in someone’s heart disease risk (mainly omega-3s, monounsaturated fats, and avoiding trans fats and processed foods). I also did some diabetes educations, which was eye-opening since I didn’t realize how generally uneducated many people are about how to control their blood sugar. One of my patients had an HbA1c of 15.1% and a BMI of 39, and when I asked her if she was doing anything special with her diet to help control her diabetes, she emphatically said yes and explained all the ways she was trying to improve her health, including buying low-fat products, eating lean meats and no eggs, and generally trying to avoid fat in general. She said she did this because she knew her triglycerides were high and didn’t want them to get higher. Meaning, she believed that triglycerides in the blood came from eating too much fat – not a strange belief, but certainly an incorrect one. I felt so sorry for this woman that she was trying hard to get a handle on her health but was going about it in all the wrong ways. In fact, she was surprised when I told her that a big bowl of oatmeal with raisins for breakfast was not a good choice for blood sugar control (I mean, oatmeal is so healthy right?), and was grateful when I explained to her the importance of balancing protein and fat with her carbohydrates. My public health education really kicked in when she explained to me all the barriers preventing her from improving her health, such as having to take the bus everywhere and not being physically able to do much exercise, along with living in an unsafe neighborhood. So her options for living a healthy lifestyle were pretty limited.

One thing that really burned me up this week was the number of patients I saw who were on statins and had total cholesterol levels below 100 mg/dL. I even saw a few in the 50-80 mg/dL range, which is absurd to me. Additionally, these patients still had a relatively high heart disease risk because their HDL was so depressed. First, I want to know what the protocol is for taking someone OFF a statin. At what point is cholesterol considered to be low enough by a doctor? Why is cholesterol one of the only blood markers that doesn’t have a lower limit to the healthy range? There is plenty of evidence to show that low cholesterol is just as dangerous as high cholesterol, so I don’t understand at all why doctors seem to think that it’s perfectly fine to leave a patient on statins when they have a total cholesterol of 58. (I’m adding some links to the end of this post showing evidence of higher mortality outcomes in cholesterol levels under 150 or so.)

The reason I got so pissed off about this situation is because as an RD, I’m still forced to put this patient on a “heart healthy diet” low in cholesterol and saturated fat. I mean, we all know that dietary cholesterol has little to do with overall cholesterol in general, and I’m not really sure why we want these patients’ cholesterol to go any lower. It seems like most people in the conventional medical system view cholesterol as a pathological molecule that should be as close to 0 mg/dL as possible for optimum health. As for me, I believe that cholesterol ranges between 180-220 mg/dL is likely the most healthy, and especially so for older adults. The possible side effects of statin use are astounding (liver damage, muscle weakness, memory loss and confusion, even Type 2 diabetes!) and yet doctors seem to be handing them out like candy. To me, I feel like keeping a patient on statins once their cholesterol levels have gone below 100 mg/dL should be considered medical malpractice.

I hate being forced to put these patients on a further cholesterol lowering diet, and I don’t believe it’s healthy or beneficial in any way. I don’t like being in the position where I have no choice but to follow hospital guidelines when everything in my brain and heart is so vehemently opposed to doing so. I try to remind myself that the diet probably won’t make a huge difference in the long run, but this experience makes me feel strongly that the guidelines for nutrition in chronic disease need a serious makeover. I’m not sure if/when that will ever happen, but all I do know is that something MUST change if we ever expect this tidal wave of chronic disease to recede in any significant way.

Anyway, check out the following articles if you’re interested in learning more about how low cholesterol may be even MORE dangerous than high cholesterol.

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  • Debbie

    This is one reason I decided to do the NTP program instead of doing the RD thing :). The other reasons are that I’m 46 with a family and don’t have the time or money. But I’m so proud of YOU for going through it so that more people will have the opportunity to learn the truth!!!

    • http://www.brentholm.com Brent

      I’m considering the NTP program but not sure how in depth it is. I’d like to be able to learn how to individualize client’s needs.

      • Debbie

        Well, it’s not like I’m learning every single bit of the biochemistry, like memorizing the Krebs cycle. So there is definitely more to learn. But the things they teach you produce some pretty amazing results!

        I’m really enjoying it and I’m helping people find out things about their own bodies that naturopaths and doctors haven’t. The neuro-lingual testing is amazing! I believe doctors and naturopaths are necessary and much smarter than me : ). And I’m sad my clients will not be able to use insurance for my services.

    • Ben

      Hey Debbie, May I ask why you chose the NTP program over something like http://www.hawthornuniversity.org/? Just curious as I’m looking into distance learning options. Thanks!

  • Zach

    Right on! Its nice to see someone who is in the health care field here at UNC who understands how important the paleo lifestyle is for health!

  • http://www.malvs2walk.blogspot.com Maryann

    So, I have a liver condition that apparently causes me to process fats differently and while on a Standard American diet, and in the total absence of any statins, my total cholesterol number always hovered around 100 and went as low as 98 once. The doctor I was seeing at the time totally freaked out and ordered all sorts of tests because she believed that cholesterol below 100 was just as dangerous as cholesterol over 200. Go figure, I have been strict Paleo for 2 years and 5 months. My numbers are finally NORMAL! Total is 174 and HDL is 72!!!

  • http://www.brentholm.com Brent

    I totally understand as an intern you aren’t going to go all paleo on them, but I personally would question everything during an internship. As long as you do it in a respectful way and they are decent people, I see no reason why you can’t have a convo about this with some open-minded people.

    Do you work alongside RD’s who are slaves to the food pyramid? Have they been at it for a while? I ask because the longer someone has been at their chosen profession, the less likely they are to actually change or critically think about anything anymore.

    I had an obese client of mine (I’m a personal trainer) who had to read an entire book so she could find out she was a sugar burner. My opinion didn’t matter because I wasn’t her nutritionist. I also know RD’s who think I’m crazy because I think saturated fat is not the devil and of course they are right because they went through formal education and are RD’s.

    I couldn’t give a flying squat what credentials someone holds. If you can’t think critically about something as important as health, you are about as qualified as my unborn child in giving out health advice. I have one of the best PT certs out there. I took a 4 hr multiple choice test. Therefore I’m an expert I guess in all things PT. Ha.

  • Sharon

    I’m sharing this w a few folks. Very very interesting.

  • http://mary-sews.blogspot.com/ Mary in FL

    My DH was on statins for just a few months, and developed diabetes (2) after that. We’ve gone paleo, and that has helped.

  • http://www.tuitnutrition.com Amy B.

    Laura, you hit it on the head. The feelings of frustration and aggravation are the reason I went for an M.S. in nutrition but not the dietetics tract. That being said, you’ll have a lot of advantages and job opportunities that are completely closed to me for no other reason than I’m not an R.D. I think RD programs are actually pretty great in terms of the biochem and physiology…it’s just wacky to see how many people forget the basic science when presented with the politically correct recommendations, and never stop to think that the two are sometimes diametrically opposed.

    I admire the patience/tolerance you must have to deal with that kind of disconnect on a daily basis, both from patients and coworkers.

    Anyway, just one thing about why doctors continue to prescribe statins for people whose cholesterol is *already* low — I think some of them actually do it as a preventive! Can you imagine? My mother’s cholesterol is just fine, and she’s on one — that’s the reason her doctor gave her! Grrr! (No wonder she can’t make it up the stairs without getting winded and has all kinds of muscle pains. Oy vey…)

    Keep fighting the good fight, girl. We need people on the inside!

  • http://www.evolvenutrition.com Susan

    Thanks so much for all the references. I have a client taking statins and his cholesterol is hovering around 130 and I’d like to get his doctor to taper him down.

  • http://wise-habits.com Carole

    Thanks for this article. I’m passing it on to my 82 year old statin-taking mom who needs to continue to hear this info from a variety of sources. Glad to hear your clinical internship is going well. It’s so refreshing to have an RD with your healthy views around diet and health.

  • grandpa

    hope to see you soon

  • http://pharmacybrute.wordpress.com Nathan S

    I wanted to comment on the frustration you feel. Being a pharmacist I feel the same way many times while counseling with patients. There is nothing more frustrating than when 70 year old men come to the window and ask why they need to take cholesterol medication. I ask the same questions over and over to many of them, “Do you have heart disease? Do you have a stent? Did you have bypass? Did you have a heart attack?” For many of them the answers are all “no” but that their cholesterol was a little high. Working in a clinic with doctors I have to be super careful not to step on their toes and it gets under my skin.

    Just remember that many of these doctors have been educated by schools who receive money from Pharma. The lower they can make the level, the more money they can make. I have chosen to work as a “health coach” or “life coach” on the side so I can more freely disseminate information that is useful to clients rather than just give them a bottle with meds.

    best o luck

  • http://drkensharlin.com Ken Sharlin, M.D.

    Laura, I completely understand your predicament. I came to Paleo/WAP long after medical school, post-graduate training, and after several years of traditional clinical practice (in neurology). It’s a tough road for us that have chosen a “mainstream” approach, but know in our hearts there is a better way. I share my knowledge with all of my patients one way or another, and for those who are particularly receptive I share in more detail. Of course I don’t know you, but you are in a position now about where to take your career. Not having at least one foot in mainstream healthcare it will be a harder road building a nutrition practice, but it may be more rewarding in the long run. I enjoy your blogs so I know you are following your passion. Good luck! By the way, I too have an MPH (from Emory) and grew up in NJ before the college years and med school in Atlanta.

    • Laura

      Luckily with an RD I’m still keeping a toe dipped in the “mainstream” side of things! Thanks for your comment, Ken!

  • https://www.facebook.com/BiomeOnboardAwareness BiomeOnboardAwareness

    Credentials… I have JD and BSME credentialing; no RD, MD. What trumps all? Not just talking the talk but walking the walk each and every day. I manage an autoimmune by diet alone being the only at UPMC, Pgh [huge teaching world renowned hospital] doing such for years (now there is about a dozen of us). SCD (for those not in the know)… less restrictive than PALEO (allowing lactose free aged cheese/homemade 24hr baked yogurt (think probiotics and micronutrients) recognizing that some PALEO camps now incorporate these if tolerated… and in other ways more restrictive (no sweet potatoes…). No “nutrition” credentialing, and yet, I now enter the corporate world, and educate, based on the science, awareness of the gut biome (and lifestyle… sleep/stress/exercise/responsible sun/toxins…) as it relates to immunity and health. Albeit my evidentiary background in criminal law and engineering helps relay incredible Power Point information in user friendly fashion, I imagine you would be phenomenal in this venue! Here, I find lots of open ears especially since I walk the walk. Amazing how once one employee jumps onboard, others follow seeing weight fall off and meds such as statins, testosterone, etc…. reduce then eliminate!