A Cholesterol Comedy, Part 1

Goals

In November 2018, I visited my general practitioner (GP) for my yearly physical. Most things looked pretty good, but he was concerned that my blood lipid panel included an elevated Low Density Lipoprotein (LDL) measurement. It was

Nov 2018
total	262
HDL	48
LDL	186*
triglycerides	142

* estimated using unspecified method (Friederwald?)

His advice was that I begin taking 20mg of Atorvastatin (AKA Lipitor) daily. I had expressed to him, somewhat timidly I now realize, that I would prefer to try lifestyle changes rather than a long-term drug therapy. My GP advised that I start taking the statin now, make lifestyle adjustments, and we recheck again in 90 days. So I filled the prescription. My out-of-pocket cost for the generic version (Lipitor's US patent expired in November 2011) was $22.74 for a 90 day supply.

When I got home, though, my reluctance blossomed into rebellion. After discussing it with my partner, I decided to try diet and exercise changes first. With a follow-up blood test already scheduled in 90 days, I set that as the milestone at which I'd judge the efficacy of my lifestyle changes.

If you asked me at that moment what my goal was, I would have said that in 90 days I wanted:

lower LDL
higher HDL
lower triglycerides

So I've got goals. Now, what strategy will I employ to achieve them?

Research

At some point in the past, I had watched a recorded lecture by Robert Lustig entitled "Sugar: The Bitter Truth". That video had fallen on deaf ears (and blind eyes, too) when I first watched it, and my dietary background is worth a brief digression.

I'll not mince words: I LOVE SUGAR. In my adult life, once free from my parent's restriction of one 12 oz. can of soda each weekend day, I consumed an obscene amount of soda (Dr. Pepper preferred). Although I certainly indulged while still in college, my fiendish behavior intensified particularly once I graduated and started working. Software developers often receive encouragement from their employers regarding caffeine and sugar intake, and I took every advantage of it. The more stress I felt, the more soda I drank. The last 18 months of my last job, ending in mid-2018, was particularly stressful, and I drank a lot of soda. Although I didn't record it, I'd estimate about 30 oz every weekday.

But I recalled a section of that video had waxed skeptical about the causal relationship between LDL and heart disease. I dug through my watched videos on YouTube and found it.

During my re-watch, this caught my attention:

Why did they [USDA, AHA, AMA] tell us to stop eating fat? In the early 1970s we discovered something in our blood called LDL: Low Density Lipoproteins. You've heard of that, right? Is it good or bad? Not so bad. We'll talk about it.

Followed by an explanation of a chain of reasoning espoused by what I'd later come to know as proponents of the Diet-Heart Hypothesis:

Dietary fat raises blood LDL.
High LDL is correlated with heart disease.
Therefore, dietary fat either causes or is-correlated-with heart disease.
Therefore, a reduced intake of dietary fat will reduce heart disease.

As a computer scientist proud to have learned formal logic from the best, this stuck out to me as deeply flawed reasoning, even with far stronger claims than the original propositions can make.

1) Given A → B
2) Given B → C
3) A → C, via transitivity of implication (so far, so good)
4) ¬A → ¬C, via... (bullshit)

So triggered by this affront to logic, and started my research with Lustig's apparent heresy. Since then, I've delved into history of a the 70 year old, running war between the "diet-heart" and "lipid-heart" hypotheses and alternative theories about the root causes of heart disease, and the role of many modern dietary trends in "diseases of modernity", the differences between epidemiological and clinical trials, the details of diet and drug trial construction, generous helpings of confirmation bias, and the messy "telephone game" of research citation, media coverage, political endorsement, and research funding. I'll get into that later.

Hypothesis

Here's my hypothesis for my 90 day experiment:

If I eliminate added sugar and get more exercise, I will lower my LDL, raise my HDL, and lower my triglycerides.

I couldn't see how either of these changes could have a negative impact, and the opportunity cost was that I delayed beginning statin therapy for 90 days (at age 40 and with only some family history of heart disease as an attendant risk factor).

Implementation - Diet

I made no effort to reduce total sugar intake, but rather immediately stopped eating anything with sugar (or one of its many synonyms) listed as an ingredient. I stopped consuming caffeine for other reasons, but it's worth noting. My partner had previously completed the Whole 30 Diet with me as more of an observer than a participant, so we started a sort of "Whole 30 light" together. I'll list a fairly typical day's menu here:

Breakfast

one piece of bacon - Applegate Organics uncured, no sugar
one piece of sausage - Applegate Naturals, classic pork breakfast
4 medium eggs, fried in bacon fat (from backyard chickens)
1.5 cup mixed greens - Ready Pac Organic Spring Mix
0.5 cup Quaker 1 Minute Oats
1 tsp Ceylon Cinnamon
3 oz raisins
12 oz Twining's decaffeinated English Breakfast tea
16 oz water

Snack - protein smoothie

10 oz milk - Kirkland Organic Whole
30 g True Nutrition Grass-Fed Whey Protein Concentrate
2 tbsp peanut butter - Kirkland Natural
1 medium banana

Lunch

8 oz pork tenderloin, roasted
0.5 cup brown rice
1.5 cup mixed greens - Ready Pac Organic Spring Mix
2 medium carrots
1 apple
16 oz water

Snack

1.3 oz Kirkland Extra Fancy Mixed Nuts
1.3 oz unsalted peanuts
1.3 oz raisins
16 oz water

Supper

12 oz top round beef steak, salted and peppered, grilled
8 oz potatoes, carrots, and beets, sliced and roasted in olive oil with salt and pepper
2 cups salad: mixed greens, carrot, celery, onion, brocolli, blueberries, sunflower seeds, pumpkin seeds
16 oz water
12 oz Celestial Seasonings Sleepytime tea

Notice that this is neither low sugar, nor low carbohydrate, nor low fat. I think it could be tersely characterized as "no added sugar, no caffeine, low processed food".

I had little trouble conforming to this "diet", although I certainly wanted to eat sugar. My ability to stick to it is partly attributable to the fact that, if this seems like a lot of food to you, that's because it is. According to Cronometer, I regularly eat 3,500-4,000 kcal/day with my body weight steady at 154-157 lbs throughout.

Implementation - Exercise

I had been following Daily Burn's "Live to Fail" (LTF) program, two or three days a week, a program comprised of mostly 40-50 minute dumbbell strength training sessions with some 20-35 minute interval training sessions. Twice a week I attend a 90 minute BJJ session (typically: 20 min warm-up, 40 min technique, 5x5 min rolling). I upped the frequency of LTF to three or four days a week, with the goal of 5 or 6 training days each week.

In the end, I did a DailyBurn workout 73 times and attended 35 BJJ classes in 145 days, averaging a workout 5.2 days per week, or just shy of 40 minutes of exercise per day.