Cholesterol, Culture, and Being Flexible!

This is a guest post from Dr. Ronesh Sinha (aka Dr. Ron). Dr. Ron is an internal medicine physician in Northern California. He specializes in helping patients from diverse ethnic backgrounds reduce heart disease risk factors through lifestyle changes. I’ve recently published Dr. Ron’s book The South Asian Health Solution. You can learn all about the book and the special offer that ends tomorrow here. Enter Dr. Ron…



I started off about a decade ago with an internal medicine practice in the heart of Silicon Valley. I learned from medical training that a typical heart attack patient is an overweight, old white guy who smokes and eats red meat. That would have been incredibly useful if I was put in a time capsule and sent back to the 1950s to practice medicine in the heart of Framingham, Massachusetts, which is where the outdated guidelines originate from. I was flooded with sedentary, mostly non-smoking, non-white, non-obese and often vegetarian patients who looked nothing like those case studies from medical training. Back then they were getting employer-based health screenings that only drew their total cholesterol level. Most of them had a total cholesterol of less than 200 and if these screenings happened to check LDL levels they often looked “good” also. These individuals were patted on their back, told they were doing great, and sent home. However, these same patients, mostly Asian Indian, were developing rampant diabetes and heart disease. One of my first heart attack cases was a 32-year-old, non-smoking Indian vegetarian. I started seeing similar cases and as I delved through the research back in those early days, I discovered that Asian Indians had one of the highest incidences of heart disease in the world. The part that puzzled me was when I looked at their cholesterol through my medically trained Framingham lens, their cholesterol numbers continued to look pretty normal…or so I thought! I went to big companies and lectured about cholesterol and feverishly preached the virtues of a low-fat, high fiber diet, one that I also practiced. However, something started happening. I never reached an overweight BMI, but my waistline did start expanding a bit and as I started checking my own numbers I noticed that my total cholesterol and LDL looked really “good,” but the other numbers on my cholesterol panel didn’t. Let’s take a look at my lipid timeline:

Look at my numbers from 7/2009. Total cholesterol of 154 mg/dL and an LDL cholesterol of 85 mg/dL. These are numbers that would make most conventionally trained physicians proud. Unfortunately, the majority of physicians ignore a far more important number, the Triglyceride-to-HDL (TG/HDL) ratio, a marker for insulin resistance, which you can see was a whopping 11.2 back then. I had developed metabolic syndrome, the dreaded insulin resistant condition that significantly increases heart attack and stroke risk. The goal is to get the TG/HDL ratio below 3.0 and the lower the better. I did do an LDL size profile as you can see from the results and it showed that I was carrying the more ominous, small dense pattern B LDL. Not necessarily ominous because of its size, but because pattern B is usually (not always) associated with greater LDL particle numbers, the real lipid risk marker for atherosclerotic plaque.

Now, as I transitioned to a more ancestrally-aligned lifestyle thanks to Mark’s Daily Apple, notice how my good cholesterol (HDL) goes up 19 points to 47, my triglycerides drop to 74 and my ratio drops to 1.6. To achieve this type of progress from the knowledge I gained from medical training I’d be taking enough of the prescription drug Niacin to make me flush and possibly raise my blood glucose, while throwing down a ton of fish oil capsules and still my results would not be as impressive. However, Dr. Framingham (not an actual doctor, but one who rigidly adheres to Framingham dogma) would cast a disapproving stare, pointing out that my total cholesterol went up 30 points to 184 and that the all-important LDL jumped 37 points. Surely that was due to all those artery-clogging egg yolks I was eating, right? Stop the eggs and here’s some Lipitor! However, notice that my LDL particle size transitioned to type A and if I had checked my LDL particle numbers back then, they would have gone down. If I’ve lost you on any of this, I use illustrations and my “6 Cholesterol Rules” in the cholesterol chapter of The South Asian Health Solution so patients and doctors clearly understand how to interpret lipid panels and when to order advanced lipid tests. In an ideal world all doctors would replace the currently outdated lipid test with an advanced test like the NMR LipoProfile, but it is still possible to make some pretty accurate risk assessments when you follow my cholesterol rules. If doctors wonder if this information is up to date, I also incorporate the 2013 cholesterol guidelines which in many ways actually supports this approach. I did a blog post on the new guidelines here. Just remember that in most cases when you reverse insulin resistance by improving your TG/HDL ratio your total cholesterol may go up thanks to a rise in your healthy HDL cholesterol and your LDL may go up too thanks to a shift from LDL subtype B to A, which means you have fewer large particles carrying more cholesterol. This phenomenon commonly elevates the LDL level on a standard lipid panel (aka “LDL-C”). I actually tell my patients and referring doctors in advance to expect a “healthy rise” in these numbers as we reduce their risk and improve their overall health. By the way, the good news is I have several doctors who refer patients to me and they are understanding and fully endorsing this approach after watching their patients reverse insulin resistance, shed excess body fat and often get off their drugs. I work in a group of over a thousand doctors and I also work with major health insurance plans who are starting to acknowledge that the current regimented, government-endorsed guidelines are failing miserably. I even have a growing panel of physicians, among whom obesity and insulin resistance are becoming a major problem, who have now become my patients since the very system they are working in is failing to give them effective risk-reducing lifestyle solutions. There’s a ton of work left to do, but I’m happy to see that there is a groundswell taking place within the medical community.

Now I want to make an important point here. I discussed how Dr. Framingham and my past self overly prescribed to regimented, outdated guidelines. When I made the transition to my current lifestyle I must admit that even my prescription of ancestral practices was initially over regimented. Although this was effective for some patients, for others it created more stress. As much as people say this way of eating is “easy,” it ain’t that easy for individuals like vegetarian Indians who come from cultures where legumes, flatbreads and rice are core staples. We also have to be careful using words like “safe starch” for rice. Yes, rice in moderation and timed appropriately can be a “safe starch” for someone who is or becomes insulin sensitive and metabolically flexible, but not for someone who is highly insulin resistant. I recently had a Chinese Google engineer come see me with advanced metabolic syndrome, telling me after his highly selective online research that he is continuing to pound large amounts of rice since it’s considered “safe.” I told him it’s not safe now, but we may be able to make it safe if he follows my plan.

Fortunately, plenty of my vegetarian Indians have been able to hang onto some of their legumes and controlled portions of rice and do just fine. I thank Mark and the Primal Blueprint Publishing team for allowing me to include this vital information in my book for vegetarians so they don’t feel excluded from this potentially life-saving approach due to rigid rules. Mark has been at the forefront of making this movement inclusive and flexible so all people can benefit, regardless of their level of motivation, instead of adopting an extreme mantra like “ditch the grains or die!” Forcing individuals to completely eliminate foods they consider integral to their culture only increases stress and possibly inflammation like this guy:

Notice how when his TG/HDL ratio was “optimal” in July 2013 at 1.8, his hsCRP was 3.6, slightly above the upper limit of 3.0. Yes he was satisfied, but not completely happy with his initial eating plan so I let him add back in some more legumes and rice. Unlike the Chinese Google engineer, this patient earned back his metabolic right to have some of these grains after he achieved insulin sensitivity through ancestral-aligned lifestyle changes. His TG/HDL ratio did go up a bit in October to 3.1, but notice how his hsCRP, a blood test marker for inflammation, dropped to an optimal level of 0.6. The hsCRP is a part of the “Metabolic 6-pack” tests I discuss in the book, which is a modification of the metabolic syndrome criteria. So this patient had a lower inflammation (hsCRP) despite his TG/HDL ratio being a touch higher, and as most of you already know, inflammation is the real underlying culprit for heart disease, chronic disease and premature aging. I see this pattern frequently enough to assume that making a diet too restrictive to adhere to rigid guidelines may be doing more harm than good. It’s not always elicited by checking a simple blood test like the hsCRP. Often you need to sit back and ask yourself if this way of living is making you happy? If the answer is a resounding no, you need to re-evaluate your choices and loosen the reins a bit. I initially may have gone from being “Dr. Rigid Framingham” to “Dr. Rigid Paleo,” but am now backing off if I sense that patients are persistently overwhelmed by my prescribed lifestyle plan. If you are killing yourself trying to achieve single digit body fat or a personal best in some endurance event, or if living in ketosis is not truly effortless due to other life obstacles or cultural constraints, you may need to back off and find a path that works and feels better for you. Stress and sleep trump everything and I focus on these in detail in my book, including devices and apps pulled from my TED talk and corporate wellness programs that have really helped struggling individuals achieve better life balance. Mark wrote up in a recent post that studies show the best exercise is the one you enjoy. This same philosophy can be applied to your diet and overall lifestyle plan. Fortunately there are a plethora of options with this style of living that can allow you to optimize health while maximizing enjoyment.

I want to end by saying thank you to Mark and the Primal team for publishing this book, and to the whole MDA community who helped guide me towards the right answers and have also served as a support community for my patients.

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