Dr. Chris Masterjohn talks about What to Do About High Cholesterol

What to Do About High Cholesterol

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Dr. Chris Masterjohn talks about What to Do About High Cholesterol
If you're concerned about your cholesterol, or confused about what to do, this episode is for you. In this episode, I list the four key factors that control blood cholesterol levels and outline the simplest dietary or lifestyle changes we can make to have the biggest impact.

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This episode is brought to you by US Wellness Meats. I use their liverwurst as a convenient way to make a sustainable habit of eating a diversity of organ meats. They also have a milder braunschweiger and an even milder head cheese that gives you similar benefits, as well as a wide array of other meat products, all from animals raised on pasture. Head to grasslandbeef.com and enter promo code “Chris” at checkout to get a 15% discount on any order that is at least 7 pounds and is at least $75 after applying the discount but under 40 pounds (it can be 39.99 lbs, but not 40). You can use this discount code not once, but twice!

Show Notes for “What to Do About High Cholesterol”

In this episode, you will find all of the following and more:

00:33  Cliff notes

09:22  Targeting the low-hanging fruit

11:50  The total-to-HDL-C ratio as a fingerprint of low LDL receptor activity

13:20  Other markers such as particle size, particle count, and ApoB as fingerprints of low LDL receptor activity

16:30  The four factors that control the LDL receptor

18:50  Intracellular free cholesterol (effects of dietary fiber, cholestyramine, statins, and polyunsaturated fatty acids or PUFAs)

20:37  Thyroid hormone (effects of micronutrients, body fat, and carbohydrate intake)

23:50  Insulin (via PCSK9, effects of the fasting-feeding cycle and carbohydrate intake)

27:00  Inflammation (via PCSK9, effects of acute infection and chronic inflammation)

29:15  Practical approaches to maximizing LDL receptor activity

29:22  Nutrient-dense whole food diets

34:00  Thyroid disorder

37:15   Adrenal stress, circadian stress, inflammatory stress

39:05  Insulin resistance, body composition, and fatty liver disease

42:00  Weight loss will improve insulin sensitivity, and for many a low-carb diet is a tool to achieve that, but in an insulin-sensitive person, carbohydrate stimulation of insulin has a powerful beneficial effect on LDL receptor activity

46:20  Inflammation and PCSK9

47:00  C-Reactive Protein levels, body composition, diet quality, and exercise

49:25  Replacing fat with carbohydrate

Posts Related to “What to Do About High Cholesterol”

Episode 16 on managing heterozygous familial hypercholesterolemia provides a more detailed background on the LDL metabolism in general but especially the regulation of PCSK9 by insulin and inflammation. The principles can be very easily adapted to managing blood lipids in someone who does not have this disease.

The Antioxidant System This is a free 14-lesson class that contains videos, slides, and transcripts. Lesson 12 covers the role of LDL oxidation in heart disease. Lesson 13 critically analyzes the evidence that replacing saturated fats with polyunsaturated fats prevents heart disease. Lesson 9 covers fatty liver disease.

For more on fatty liver disease, see Start Here for Fatty Liver Disease.

Episode 11 on how body fat and carbohydrate intake influence thyroid hormones.

Episode 25 on what causes insulin resistance at the cellular level.

Episode 26 on what causes insulin resistance at the systemic level.

Oldie but goodie: The Total-to-HDL-Cholesterol Ratio — What Does It Mean?

My three-part interview with Chris Kresser on blood lipids: part 1, part 2, part 3.

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41 Comments

  1. This is the most elucidating podcast I have heard on this subject. Amazing point about the confusion between the merits of a LCHF diet on reducing CVD risk / improving insulin sensitivity being applied by people who are ALREADY insulin sensitive.

  2. Hi Chris. I haven’t quite seen anyone ask what to do if you have a high Total C to HDL ratio. Mine is a ratio of 4.39
    C 150
    Trigly 189
    HDL 57
    LDL 155
    VLDL 38

    My doctor thinks my cholesterol is going too high and the ratio is higher than the range you stated of 3-4. I can’t figure out why it is high because I don’t think I have any of the issues with Liver, Insulin, Thyroid or Chronic Inflammation.
    I’m 46 and active–yoga practice several times a week, dance classes, and daily natural movement of crawling, climbing, hanging, walking, hiking . I eat really well with grass-fed meats, organic produce, home-cooked meals, very little processed foods or junk foods. Although, I do like red meat and grass-fed butter, so I could cut back on those. I feel good other than mild depression that comes and goes and occasional energy lags.
    I don’t feel that I have any systemic inflammation, though I haven’t checked C-Reactive Proteins. And I am at a good weight with clear skin and good hair. I sleep well and I am rarely sick and when I do get a cold, my system clears it quickly.

    I’m not sure how much I should be concerned and trying to reduce my cholesterol or whether it is fine and I should just continue my current diet/activity level.

    I don’t know if you look at these comments anymore, but I would love your feedback if you have time or inclination.

  3. Thank you for this wonderful episode. I think you may have just saved me from a cascade of decisions that I made, which resulted in poor health. Three and a half years ago, I was a “Normie” who jumped on the Keto bandwagon… primarily for brain health (vascular dementia and Alzheimer’s in multiple family members) with the benefit of lose 3 to 5 pounds. Fast forward to today I have become one of those folks with great HDL/Cholesterol Ratio, High Total Cholesterol, High LDL-C, High ApoB, high-end of normal for TSH, low-end of normal for Free T3 and Free T4. Needless to say, somewhere over the years, I developed arterial stenosis from Atherosclerosis in my anterior cerebral artery, carotid arteries, and renal arteries. My doctor recommended low-dose Thyroid NP, which was a diaster (stopped taking), and a daily dose of L-Arginine Plus (no change in carotid soft plaque after 90 days). Meanwhile thanks in part to your words of wisdom, I have been working to reduce my stress (meditation and working less), and have finally got my circadian rhythm on track (from insomnia). I am taking daily supplements of L-Arginine, K2 (mk7), Ashawaganda, and Calm Magnesium Powder. I have reduced my saturated fats significantly, adding in more nutrient dense carbohydrates. I am working my way out of Keto, currently at 70 carbs (35 net carbs). My goal over the next couple of months is to lead a moderate-carb (up to 150 grams) Paleo lifestyle. I will redo labs in 3 months! Wish me luck!

    THANK YOU SO MUCH CHRIS!

  4. Hi Chris,

    Do you have any thoughts on lipoprotein(a) as an independent risk factor for CVD, and if that marker affects the guidelines you’ve laid out here? For instance, if someone has a good total-to-HDL-C ratio (below 4), but a very high lipoprotein(a) count (200+).

    For reference/context, the New York Times this week just published a pretty alarmist (and somewhat fatalistic) article about it:

    https://www.nytimes.com/2018/01/09/well/heart-risk-doctors-lipoprotein.html

    Thanks so much for your fantastic work.

  5. Hi Chris,
    I am a 53 yo female with a very healthy diet(former Paleo) now just whole foods, crossfit, run walk. My blood panel just came back with
    TC 290
    HDL 104
    Ratio 2.8
    LDL 173
    Non HDL 186
    Should I be concerned about theses numbers?My Dr. didn’t request particle count/size, ApoB or C-RP. Do I need those markers to know if there is really anything to be concerned about?

  6. Hi Chris,
    I’m in the UK and have just had some bloods done and my results have come back as
    Total Chol: 363
    LDL – 227
    HDL – 119
    Trig – 89
    I’m 51 and I have been on a primal/paleo diet with lowish carbs for nearly 2 years but eat plenty of vegetables. This has allowed me to lose around 50lbs in weight.My blood pressure is normal and I exercise regularly; a mix of bodyweight training, HIIT and plenty of walking. I have no know family history of heart disease.

    Should I be concerned about these results, especially as my Total/HDL ratio is around 3 and my Trig/HDL ratio is less than 1? Would you recommend any other blood tests to assess my status further?

  7. Hi Chris, great episode, but I want to make sure I have this right:
    I have a very low insulin score (4), and am lean and insulin-sensitive by all measures. I also have high LDL (200), high total (300), fairly high HDL (78), and low trig (78). My oxidized LDL (measured for the first time recently) is extremely high (116). My LDL particle count is 2400 and my SD-LDL particle count is 949. I’d like to get the unfavorable number, particularly the oxidized LDL, down considerably.

    If I’m reading the transcript of this episode correctly, someone with those stats should not be eating LCHF with sometimes only two meals/day, but rather should be eating three meals/day with lower sat-fat and higher clean carbs, like lentils or sweet potatoes. Doing so will trigger an insulin response that the insulin-sensitive person can handle, and that insulin response will activate LDL receptor sites.

    Do I have that right? And does an APOE 2/3 status (which normally indicates poor handling of carbs) affect this calculus? Thanks for all you do, and I’m looking forward to your answer.

  8. I noticed in this and other podcasts, you mentioned PCSK9 a few times, but not the recent drugs that target it. What is your take on recent Fourier Study results http://www.nejm.org/doi/pdf/10.1056/NEJMoa1615664 ? I read mixed opinions, some focus on reduced cardio events, others – on increased cardiovascular and overall mortality in treatment group, all despite greatly reduced LDL.

    1. Joe, I’m not interested in it. First, they are enormously expensive. Second, potatoes are a lot cheaper.

      1. Fair enough, and I appreciate the focus on nutrition. But, but … A experiment with a drug like this should in theory validate or invalidate the theory that activating LDL receptors is hugely beneficial for CHD outcomes (with potatoes or drugs), no? Or we are steering into comparing apples with potatoes too much here for it to be relevant?

        1. Joe, you say this like this hasn’t been tested, but it’s been investigated in larger numbers from more angles than any other health-related hypothesis in biology.

          1. I’ve been looking at it from the angle of lipid lowering during primary prevention for reducing mortality, and although you are right about the amount of research that had gone into this, the conclusion still does not appear to be a slam dunk to me. the best summary I had been able to find being this one https://www.ncbi.nlm.nih.gov/pubmed/26376908 (Perhaps you could point out a better resource?) where most agents for reducing LDL don’t mention reducing overall mortality; the latest PCSK9 trial seems somewhat typical from that point of view.

    1. As a reference point, I had my gallbladder removed about 10 years ago and I seem to have no trouble digesting fat. I actually use a mildly ketogenic diet in response to my homozygote ApoE4 status to address reduced cerebral glucose utilization. I’d be hesitant to use your gallbladder removal as an excuse to cut dietary fat.

  9. Thank you for this information. I am new to your site. Perhaps you have covered my question already… but how does weight loss impact cholesterol levels? Can we lose these locked cholesterol esters formed from eating polyunsaturated fats or monounsaturated fats? You have me thinking it might be good not to have so much olive oil in my diet. Thank you again, best wishes for your endeavors 🙂

  10. Well that was a compelling listen for sure…

    I have always had problems with chronically low (sometimes as low as 15) HDL -C and high TG’s. LDL has tended to bounce around unpredictably. I started a keto regimen in January that has had great effects on my body comp, weight, and mental clarity. It has not been great for my lipids though.

    I took my first NMR in February (only a month into keto so I plan to repeat in another month or two) and was horrified to see that my LDL-P was 1721 (small LDL-P 1155), HDL-C was 25, LDL-C 179, and TG’s 185 (these were actually down from a previous test where they were over 200). Their “LP – Insulin Resistance” score had me at 45 which is top of the normal range. H1AC was 5.4.

    To be clear, my lipid profile was not great before keto, but I had never had an NMR, so there’s no baseline from a particle/particle size standpoint. I do know that I’m highly reactive to carbs and feel a heck of a lot better when I’m below 20 grams per day….

    Here’s my question: thyroid numbers were pretty normal from a range standpoint (though TSH was 3.0) but I have long suspected sub-clinical hypothyroidism based on long-standing symptoms. I plan to begin natural desiccated thyroid, selenium, and iodine if my Dr. approves.

    Do you typically find that it is only obvious cases of thyroid dysfunction that drive lipid problems, or can sub-clinical thyroid issues cause the sorts of issues called out in your podcast? If one supplements with NDT and iodine, will there potentially be less negative impact on lipid metabolism, or would you still expect that supplementation would not overcome the impacts from a LCHF diet on thyroid function?

    I guess I’m looking for hope that I can stay low-carb, but the info here has me re-thinking that…

  11. heartattacknew.com offers interesting information (new) perspective to consider – in my opinion. I see cholesterol fear as a patsy or scapegoat that not only diverts from true causes but corals the herd into a statin and associated revenue stream. Taking non-pharma approaches to this issue still needs to be based in a true account of the risks and balances to why one would do so. Studies are often suspect – as anyone who is not blindly trusting of ‘authorities’ soon comes to realize. Corporate influence is a huge bias to every human institutional dependence upon it.

  12. On a very strict paleo diet (no dairy, grains, sugar) my total cholesterol was 446 with a chol/HDL ratio of 3.08. My homocysteine was 7.3, my C reactive protein was 0.02, and my particle size was big and fluffy. Everyone was quite (that’s an understatement) concerned only about the total number, so I eventually tried a low-fat vegan diet. After 2 months, my total cholesterol was 152 with a ratio of 2.27.
    Obviously diet affects me greatly, but now I am confused as to what I should be eating! Any thoughts would be greatly appreciated.
    Thank you.

    1. I do not feel comfortable telling you personally what to eat in the context of blog comments, but considering the information in your story on its own, it would seem you’ve collected evidence in favor of eating lower fat.

  13. Hey Chris ,

    Thanks for the great info which no general doctor would be able to even touch base on.

    Any idea when / if you are close to taking on any new clients for nutritional consulting ?

    1. Hi Calvin, the earliest that I might take on new clients would be June 1. You’re welcome for the information.

  14. It’s “Cliff’s Notes.”

    I don’t know much and have very little to contribute to this discussion, so I’ll toss that in as my contribution! 🙂

  15. Great information. I love your emphasis on context. I am one of those that follow a very ketogenic diet even though I have a very low body fat % and am very insulin senstitive. I relooked at my last NMR number in light of the information in this episode. My total:Hdl is around 5 with absolute numbers TC 721 and hdl 140. All other numbers are great (inflammation, particle size,etc).
    I’m a hyper responder to lchf so thought you would find it interesting. I know you’re advice was to lower saturated fat and increase carbs and fiber in my case but that leads to GI discomfort…I just feel better on low carbs, so I’ll stay the course.

    1. I think you have underlying problems that you need to work on to improve carbohydrate tolerance. There really is no conceivable context in which a total cholesterol of 721 is not deeply concerning.

  16. What do you think about people with good ratios but high Total or LDL? I’ve switched to a lower carb diet, but continue to see numbers like this:

    Total: 222 (>200 abnormal)
    HDL: 62
    LDL-C: 144 (>100 abnormal)

    Ratio is ~ 3.6:1 or slightly better based on some other older labs that were around 3.3.

    While the ratio seems good, both LDL-C and Total are clearly above normal ranges.

    1. Andy, that total is not all that high. I wouldn’t read much into it unless there are other health problems.

      1. Hello,
        I want to help my father. He has total C of 243
        LDL 173 mg
        HDL 42 mg
        He doesn’t eat a lot, only sometimes on celebrations. He has a big tight belly. Normal legs.

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