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.

References:

• Modeling total cholesterol as predictor of mortality: the low-cholesterol paradox.
• Point: Why statins have failed to reduce mortality in just about anybody.
• Drug Treatment of Hyperlipidemia in Women
• Cholesterol as risk factor for mortality in elderly women.
• Low cholesterol is associated with mortality from stroke, heart disease, and cancer: the Jichi Medical School Cohort Study.
• Which Cholesterol Level Is Related to the Lowest Mortality in Population with Low Mean Cholesterol Level: A 6.4-Year Follow-up Study of 482,472 Korean Men
• Low total cholesterol and increased risk of dying: are low levels clinical warning signs in the elderly? Results from the Italian Longitudinal Study on Aging.
• Serum cholesterol level and mortality findings for men screened in the Multiple Risk Factor Intervention Trial. Multiple Risk Factor Intervention Trial Research Group.
• Relationship among low cholesterol levels, depressive symptoms, aggression, hostility, and cynicism.
• Low cholesterol is associated with mortality from cardiovascular diseases: a dynamic cohort study in Korean adults.
• Baseline characteristics and hospital mortality in the Acute Heart Failure Database (AHEAD) Main registry.
• Low serum cholesterol concentration and short term mortality from injuries in men and women.