Doc’s Talk 08-19-2012

Dr. Scaff talked about cholesterol.

Dr. Scaff reminded everyone of what he said several weeks ago, that he would like people to challenge thoughts, and do some reading on the topics he discusses.  Do not assume that these are all his ideas.

One of the best books on nutrition is Know Your Fats” by Mary G. Enig, Ph.D.  Who is Mary Enig?  She was Chair of the Maryland Department of Nutrition.  She was also on the McGovern Committee that came up with the Low Fat Diet, and she declared that the food pyramid is upside down. Dr. Scaff knows her well, and has had some communications with her.  If you want “the skinny” on fat or cholesterol, this is the best book there is.  You can get it through the mail for about $18 or on e-Bay for a little bit less.  It is an excellent book.

It seems that we have a national agenda against cholesterol.  Who feels good about cholesterol?  What would you say if Dr. Scaff told you your cholesterol was too low and you needed to have a cholesterol transfusion?  Well, that could be true.

Cholesterol is called an artery clogging fat.  Actually, cholesterol does clog arteries but it is not a fat, it was mislabeled; it is a benzene ring sterol, an alcohol.

Cholesterol is the building block of every cell in our bodies.  Without cholesterol we would have a life expectancy of 20 or 30 seconds.  Just like sugar or anything else, too little cholesterol you don’t live, too much cholesterol you don’t live.  There has got to be a balance.  Cholesterol is so important that the liver manufactures 3 grams each day.  The recommendation is 300 milligrams a day.  If you eat 300 milligrams, the liver makes 2.7 grams.  The circulating cholesterol level stays consistently the same.

Dietary cholesterol is unrelated to serum cholesterol.  You cannot eat enough cholesterol to change the total body load of cholesterol.

The building block
Cholesterol is the building block for life, liberty, and the pursuit of happiness.

Life: Cholesterol surrounds every red blood cell membrane, and every nerve membrane, and every cell in your brain.  If you were autopsied and we cremated your brain, the dry weight of your brain is 55 to 60 percent cholesterol.  Without it you’d be dumb.

Liberty:  The adrenal glands produce the salt regulating enzymes and everything that maintains your blood pressure and these substances are made out of cholesterol.

Pursuit of Happiness:  Your sex hormones, testosterone and estrogen, are made out of cholesterol.  Some people say we should not let adolescent girls eat cholesterol because it causes raging hormones, and they are partly correct.

So, we need a lot of cholesterol, we just don’t need too much.

What is the ideal level of cholesterol?
160 to about 220 milligrams is a good range to be in
.  Most people would like to be under 200, but that is ok.

But as you know, if you look at the chart from the American Heart Association, deaths from heart attacks (the commonest cause of death related to cholesterol other than stroke and hypertension) increases by only 2 – 3 percent with a serum cholesterol level between 140 and 200.  With a serum cholesterol level approaching 220 heart attacks increase, and at 240 deaths from heart attacks double – that is an important number.  From 240 – 280 the rate of deaths from heart attack doubles again.  So a person with a cholesterol of 280 is 4 times as likely to die of a heart attack than someone with cholesterol of 220 or less.  So 280 is another important number.  However, if you exercise and cannot get your cholesterol down, and that reduces morbidity and mortality by 30 percent, you fall into an entirely different group.  That is all we had to offer before some of the statins and similar drugs.  With cholesterol below 150 the death rate increases again and approximates the death rate of the high cholesterol.

Dr. Scaff has had patients who have had heart attacks when they are on statins, and their cholesterol is down to 110 and they are happy as can be.  Their HDL is low though, which is not good.  He had one patient who had a heart attack at age 41 and his cholesterol was never over 160 – 170.  The patient did not exercise of course, but that is a different story.   So there are a whole bunch of parameters involved.

After the Heart Association came out with the Low Cholesterol Diet it was discovered that some people with cholesterols of 180 were having heart attacks, and they also found people with cholesterols of 290 who Never had a heart attack.  It turns out that there are different types of cholesterol.  The “bad” one is the so-called LDL, the “good” one is the so-called HDL.  And it turns out there is one type of HDL that is better than others.

So a simple way to look at cholesterol is as a balance.  What happens is we either eat cholesterol or we manufacture it.  Cholesterol is then attached to a protein called an LDL (Low-Density Lipoprotein) or a VLDL (Very Low Density Lipoprotein), or HDL (High Density Lipoprotein).  From the manufacturing site in the gut, all cholesterol goes to the liver first through IDL (Intermediate Density Lipoprotein), a quark, and then it is released to go to receptor sites such as the muscle, the brain, etc.  Cholesterol has to be loosely bound or it will not be picked up.  So the LDL carries cholesterol loosely bound.  HDL picks up the excess that is left and binds it so that it is no longer available for use in the body, and takes it back to the liver where it is broken down into bile salts, released into the gut and turns your stool brown.  If your stool is brown you have normal metabolism.  Then the LDL picks up what is left over again and recycles it.

So what you need is a balance of all of cholesterol.  A very simple way to look at it is HDL.  If you have a ratio of less then 4 (total cholesterol 200, HDL 50 = 4) the probability of premature heart disease is negligible, and if reversal of atherosclerosis can occur, it will occur in this milieu.  Ask your doctor, “Have you seen a person with an HDL over 50 with premature heart disease?”  Rarely!  Smokers or those with some other situations maybe.

Remember there is no active process to lay cholesterol down in the arterial walls, it is passive.  We can see cholesterol go into the arterial wall, and when we raise the HDL, we can see it come back out of the wall.  So what you really want to look at is your HDL cholesterol ratio.

Everybody has been obsessed with LDL, but a funny thing happened this year at Diagnostic Laboratory Services.  They appreciate that LDL is not that important, so they quit reporting it.  Now the doctor who thinks LDL is important has to calculate it by a formula, but we are using all the other data, so what does it mean?  We are abstracting it.  Now we are coming up with something called the Non-HDL cholesterol.  Non-HDL cholesterol is total cholesterol minus HDL.  Total cholesterol of 200 – HDL of 50 = Non-HDL of 150.  The ideal non-HDL cholesterol is 138 or less.  Those are the numbers to look at.

Dr. Scaff notes that he does not have enough experience with this to say that non-HDL cholesterol is more potent than the HDL cholesterol ratio, because they just started publishing it regularly this year, but some doctors are saying that.  However, HDL cholesterol ratios worked in his practice for 40 years, and Dr. Scaff says nobody dies on his watch.  He tells his patients that they are NOT going to have a heart attack.  They may get hit by a car while jogging, or something like that, …and maybe that is a “cholesterol related death” in that you are trying to take care of your heart and you get hit by a side-effect (the car).

Statins are very powerful drugs, but remember, the way you change anything in the body is by poisoning an enzyme system.  All drugs are poisons.  When you take an antibiotic it poisons the germ more than it poisons you.  We now know of the muscle problems associated with statins.  There is a new condition called statin dementia, where people become senile with statins.  Dr. Scaff had a very tragic case in his practice where the person insisted on being on statins, and went senile within 6 months.  The patient was put in a nursing home with a do not resuscitate order, and when they quit administering the statins, he woke up and recognized his family.  The man was never well enough to get out of the hospital, but that is an example of the risks.  Five percent of people on statins develop diabetes.  Which is the bigger risk factor?  They say you should take your statin, but diabetes is a much bigger risk factor as far as Dr. Scaff is concerned.

So you’ve got to really be careful when you get into this kind of stuff, particularly when there is so much literature available on the market.  And you ought to be reading the literature, don’t just accept everything that is said.

As a final thought, Dr. Scaff shared something that recently came out in the newspaper:  “Eating Egg Yokes Almost As Dangerous As Smoking”.  (And Dr. Scaff is saying eggs are good for you!)  But at the bottom of the article they note: “But there is conflicting research on whether eggs affect people’s cholesterol level.”  So they say eggs are as dangerous as smoking then they say, “But we don’t know.”  So read Mary Enig, she knows everything!

There are many pages of information on cholesterol and nutrition, including Chapter 35 “The Omnivore’s Guide to Perfect Nutrition”, in Your First Marathon – The Last Word In Long Distance Running, by Jack H. Scaff Jr., M.D., F.A.C.S.M., available for purchase at the Honolulu Marathon Clinic on Sundays and online at:

For more good reading on nutrition, Dr. Scaff recommends everyone check out the daily postings on Dr. Alan Titchenal’s “Got Nutrients?” web site:

Here is a recent posting:


August 13, 2012
Daily aspirin use is associated with reduced risk of cancer and cardiovascular disease. If your doctor has recommended daily aspirin, remember to always take it with food. Even low-dose aspirin can cause serious gastrointestinal bleeding and stomach ulcers when taken regularly on an empty stomach.

Consumer Link
Daily Aspirin Usage Linked to Lower Cancer Mortality

Research Link
Journal of the National Cancer Institute, August 10, 2012 DOI: 10.1093/jnci/djs318