All posts by smartersig

Total Cholesterol/Heart Disease by Country

Looking at the World Health Organisation data on average total cholesterol levels for men aged 25+ and then marrying that with the highest risk countries for heart disease and the lowest risk countries for heart disease one would expect, if the the doctors are correct, to see a glaring message. Well you decide. Which group do you think is the top risk group and bottom risk group for heart disease based on the countries average total cholesterol shown to the right.

Turkmenistan 4.5
Russia 4.9
Bulgaria 5.0
Romania 4.9
Hungary 5.1
Argentina 5.0

France 5.3
Australia 5.1
Luxembourg 5.5
Switzerland 5.3
Japan 5.2
Israel 5.0


LCHF Diets

Low carb high fat diets are very much in vogue at the moment and they are without doubt effective for weight loss, blood sugar control and epilepsy treatment. Evidence on how they effect long term CVD risk however is a bit thin on the ground. There was one accidental study referenced on and copied below. The slight worry however is that the author of the study was prosecuted for medicare billing fraud and failing to carry out research he was paid for by a soy product company. This does not mean what he highlighted below is worthless but then again on its own it would have not been conclusive anyway

There has only been one study ever done measuring actual blood flow to the heart muscles of people eating low-carb diets. Dr. Richard Fleming, an accomplished nuclear cardiologist, enrolled 26 people into a comprehensive study of the effects of diet on cardiac function using the latest in nuclear imaging technology–so-called SPECT scans, enabling him to actually directly measure the blood flow within the coronary arteries.

He then put them all on a healthy vegetarian diet, and a year later the scans were repeated. By that time, however, ten of the patients had jumped ship onto the low carb bandwagon. At first I bet he was disappointed, but surely soon realized he had an unparalleled research opportunity dropped into his lap. Here he had extensive imaging of ten people before and after following a low carb diet and 16 following a high carb diet. What would their hearts look like at the end of the year? We can talk about risk factors all we want, but compared to the veg group, did the coronary heart disease of the patients following the Atkins-like diets improve, worsen, or stay the same?

Those sticking to the vegetarian diet showed a reversal of their heart disease as expected. Their partially clogged arteries literally got cleaned out. They had 20% less atherosclerotic plaque in their arteries at the end of the year than at the beginning. What happened to those who abandoned the treatment diet, and switched over to the low-carb diet? Their condition significantly worsened. 40% to 50% more artery clogging at the end of the year.“.

This study seems to be the best I can come up with so far

It suggests a significant increase in overall mortality for LCHF and no significant increased risk for death from CVD or incidence of CVD. Interestingly though the risk ratios for CVD are a tad over 1.0 which would possibly add weight to the argument that setting out in life on LCHF is not particularly going to kill you from CVD, it is either neutral or at worse so marginally negative that something else is going to get you first. However perhaps in the battle to reverse heart disease (if you accept that this can be achieved) you need some protocol that can improve on neutral.

FOOTNOTE – The following from the Harvard school of public health offers more encouragement for LCHF but with a proviso from where the fat comes from

Low carbohydrate diets and heart disease

Research shows that a moderately low-carbohydrate diet can help the heart, as long as protein and fat selections come from healthy sources.

A 20-year prospective study of 82,802 women looked at the relationship between lower carbohydrate diets and heart disease; a subsequent study looked at lower carbohydrate diets and risk of diabetes. Women who ate low-carbohydrate diets that were high in vegetable sources of fat or protein had a 30 percent lower risk of heart disease (4) and about a 20 percent lower risk of type 2 diabetes, (34) compared to women who ate high-carbohydrate, low-fat diets. But women who ate low-carbohydrate diets that were high in animal fats or proteins did not see any such benefits. (4,34)
More evidence of the heart benefits from a lower-carbohydrate approach comes from a randomized trial known as the Optimal Macronutrient Intake Trial for Heart Health (OmniHeart). (35) A healthy diet that replaced some carbohydrate with protein or fat did a better job of lowering blood pressure and “bad” LDL cholesterol than a healthy, higher-carbohydrate diet.
Similarly, the small “EcoAtkins” weight loss trial compared a low-fat, high-carbohydrate vegetarian diet to a low-carbohydrate vegan diet that was high in vegetable protein and fat. While weight loss was similar on the two diets, study subjects who followed the low-carbohydrate “EcoAtkins” diet saw improvements in blood lipids and blood pressure. (36)


1. Mozaffarian D, Hao T, Rimm EB, Willett WC, Hu FB. Changes in diet and lifestyle and long-term weight gain in women and men. N Engl J Med. 2011;364:2392-404.

4. Halton TL, Willett WC, Liu S, et al. Low-carbohydrate-diet score and the risk of coronary heart disease in women. N Engl J Med. 2006;355:1991-2002.

31. Foster GD, Wyatt HR, Hill JO, et al. A randomized trial of a low-carbohydrate diet for obesity. N Engl J Med. 2003;348:2082-90.

32. Samaha FF, Iqbal N, Seshadri P, et al. A low-carbohydrate as compared with a low-fat diet in severe obesity. N Engl J Med. 2003;348:2074-81.

33. Sacks FM, Bray GA, Carey VJ, et al. Comparison of weight-loss diets with different compositions of fat, protein, and carbohydrates. N Engl J Med. 2009;360:859-73.

34. Halton TL, Liu S, Manson JE, Hu FB. Low-carbohydrate-diet score and risk of type 2 diabetes in women. Am J Clin Nutr. 2008;87:339-46.

35. Appel LJ, Sacks FM, Carey VJ, et al. Effects of protein, monounsaturated fat, and carbohydrate intake on blood pressure and serum lipids: results of the OmniHeart randomized trial. JAMA. 2005;294:2455-64.

36. Jenkins DJ, Wong JM, Kendall CW, et al. The effect of a plant-based low-carbohydrate (“Eco-Atkins”) diet on body weight and blood lipid concentrations in hyperlipidemic subjects. Arch Intern Med. 2009;169:1046-54.

Why I am Pesco-Vegan ish

I dont think there is an official classification as Pesco Vegan but it comes closest to describing how I eat these days. I avoid dairy and meat but eat fish such as wild salmon, mackerel, sardines and my favourite anchovies on sliced tomato. I try not be too neurotic about food. For example if you invited me to your house and chicken was on the only choice I would eat it, happy that this means I am eating chicken only once every blue moon.

Getting into a debate on Vegan/Pesco etc Vs meat eaters with regard to health and longevity can be pretty hairy if you are in the wrong company. I must be one of few people who have taken a battering on ( a veggie based community) for my suggestion that cholesterol levels are not the main driver of heart disease whilst getting similar treatment on Dr Kendricks blog which is populated by saturated fat and meat advocates when suggesting that Pesco’s are the top dogs in the health game.

The main problem with the latter debate is the existence of confounders. For example randomly looking at meat eaters against vegetarians may well include more smokers in the former and the fact that the latter have made some conscious diet changing move could mean they are generally more health living types.

The study I like quoting however is the Adventist Health Study 1 and 2

In this study Pescos clearly came out top with the lowest risk ratio for overall mortality. I like this study because it has a relatively tight cohort in that all subjects are from the same religious group and hence have closer matched support networks than taking subjects from the general population.

Med’Diet V Statins

“Recently, researchers in Lyon, France, prospectively studied the effects of the Cretan Mediterranean diet on a group of 605 postmyocardial infarction patients (9). Patients were randomized either to the Cretan diet or to a “prudent” diet similar in composition to the American Heart Association Step 1 diet (control group). All other aspects of the patients’ health care were identical. An astonishing 70% reduction in the incidence of subsequent death and nonfatal myocardial infarction was reported in patients on the Mediterranean diet after a mean follow-up of 27 months, a ratio that was maintained through a final 48-month mean follow-up (10). Even more remarkable is that this mortality benefit occurred despite no difference between the study and the control populations in follow-up LDL and HDL cholesterol levels and only a very modest 6% drop in total cholesterol levels in both groups from 250 mg/dL to 237 mg/dL. The magnitude of benefit reported with the diet alone should be contrasted with that achievable by other routine secondary prevention therapies, including statin drugs (35% event reduction) (11), beta-blockers (15% reduction), and angiotensin-converting enzyme inhibitors (20% reduction) (12).”

Pescitarians are the longest living amongst dietary categories. The success of the Med’ diet may have something to do with fish.

“Two large prospective studies have reviewed the benefit of fish oil. The Diet and Reinfarction Trial (DART) randomized 2033 men to either a low-fat diet, a high-fiber diet, or a 200- to 400-g per week fish diet (30). There was a remarkable 29% reduction in all-cause mortality at 2 years in the fish diet group vs the other 2 groups. An even larger 62% reduction in ischemic heart disease death was noted in those patients who chose to take fish oil tablets (900 mg omega-3 per day) rather than eat fish. Fish oil has antithrombotic, antiarrhythmic, and anti-inflammatory properties in addition to lipid-lowering effects, which probably account for these results. This may help explain the beneficial results found in the a-linolenic acid–rich Mediterranean diet, as alinolenic acid is converted to DHA and EPA in the body. DART, however, had a number of confounding factors in its intricate multifactorial design, and the results are tantalizing but not convincing.

The larger GISSI Prevention Study randomized 11,324 Italians with recent myocardial infarctions to 850 mg of omega-3 fatty acids per day, 300 mg of vitamin E per day, neither, or both (31). In the fish oil group there was a statistically significant 20% reduction in total mortality at 3.5 years and a more striking 45% reduction in sudden death, reinforcing a possible antiarrhythmic property of omega-3 fatty acids. Although this study was not designed to investigate this hypothesis, a large majority of the study subjects appeared to be eating components of a Mediterranean diet at baseline, and the extra fish oil produced additive benefits.”

Machine Learning Takes on Heart Disease Risk

Machine learning is a process where computers are used to analyse past data in the hope of predicting outcomes from future data. These outcomes can be anything in the modern world of Machine Learning, ranging from what type of book or CD you are likely to buy to predicting the outcomes of sports events such as horse racing. Various different Machine Learning methods have been devised each with different strengths that can make them more applicable to different types of problems. So a Neural Network may perform better on one kind of problem than say a Random Forest algorithm, but less efficiently on another kind of problem. Risk factor calculators that you plug your data into on the web are based on simpler models which assume a linear relationship between the factors eg LDL, blood pressure etc. Machine learning algorithms can dig deeper so to speak and amongst other things, uncover weightings to various factors. Figure out which are most important and weight them accordingly.

Such an approach was taken with a 10 year project tracking people with 48 factors. Four different algorithms were employed on the data. The data was split into 75% to find out what the relationships were within the data, usually called ‘training’ the model in machine learning parlance. The remaining 25% was used to test how well the model could predict cardio events such as heart attacks. The results were pretty good, out performing conventional risk assessors. Taking an average of how the four methods ranked the different factors we can see that LDL is well behind HDL, Trig’s and HbA1c as a risk factor. Here is an ordered table of those averages showing that age (not surprisingly) was the most impactful feature. Note that some are negatively significant eg Women are significantly less likely to have an event). ‘Missing’ means within the data a patient had this data missing. here is a link to the report

Ethnicitya: South Asian
SESb: 2nd Townsend quintile
Ethnicitya: Black/Afro-Caribbean
SESb: 3rd Townsend quintile
SESb: 4th Townsend quintile
HDL cholesterol*
Oral corticosteroid prescribed
HbA1c missing
Total cholesterol*
Systolic blood pressure*
Ethnicitya: Other/Mixed
SESb: 5th Townsend quintile (most deprived)
Atrial fibrillation
Family history of CHD < 60 years
SESb: Unknown
AST/ALT ratio missing
Ethnicitya: Chinese/East Asian
BMI missing
Ethnicitya: Unknown
Serum creatinine
Immunosuppressant prescribed
gamma GT
Chronic kidney disease
Anti-psychotic drug prescribed
Severe mental illness
Rheumatoid arthritis
Blood pressure treatment*
LDL cholesterol
gamma GT missing
AST/ALT ratio
Serum creatinine missing
FEV1 missing
Serum fibrinogen
CRP missing
Serum fibrinogen missing
LDL cholesterol missing
Triglycerides missing

Over the Pasta and discovering NLR

During February I had a reminder of the dangers of over consumption of simple Carb’s. I spent a week in Rome and if you have been there you will know its wall to wall Pasta and Pizza. After a couple of days I just gave up and decided to eat the stuff for the remaining 5 days. I normally never touch Pizza and Pasta but made an exception in Rome. Now I normally spend a few months away in the winter and return to the UK exactly the same weight courtesy of the excellent dietary habits of the Portugese. A week in Rome however found me 7lbs overweight. This was a stark reminder of how damaging these products are.
Perhaps on a more interesting note I have just stumbled upon an inflamatory marker that has been shown to be a very good predictor of future or current heart disease. It is called the Neutrophil to Lymphocyte ratio and has been show to improve the Framingham risk score for any one who believes in the Framingham score (probably the people from Framinghan do). As usual this test can be obtained cheaply in Portugal for 6 euros. More details on the ratio can be obtained from the link below.

Just got my NLR results back. My Neurtrophil reading is 3.57 whilst my Lymphocyte reading is 2.08 giving a ratio of 3.57 / 2.08 = 1.71. The acceptable range is 0.78 to 3.53. Higher than 3.53 would be considered a problematic reading.

HDL Efflux

Higher HDL levels are generally associated with decreased risk for heart disease because of its role in transporting cholesterol away from macrophages within the artery wall back to the liver for recycling. However it seems that the amount of HDL is not the primary driver of improvement in this area. HDL Efflux appears to be the main driver and refers to how good HDL is at ‘sucking’ up cholesterol. You can have HDL C levels above 2.0 mmol but if your Efflux is low the hoover just ain’t picking up the bits. This may explain why very high levels of HDL dont seem to be better than just above average levels.

How can we improve HDL Efflux, well it seems the good old Med’ diet comes to fore once again along with a moderate (glass with a meal) amount of red wine. More controversially for me and other more expert in the field is the advocacy of extra virgin olive oil. Nothing seems to split the heart health community like this ingredient. Some research swear by it whilst others clearly show it creates endothelial disfunction. My feelings are that when confronted with split opinions like this I prefer to leave it out of my diet especially when its non essential. I will stick with a med’ based diet and a handful of nuts each day.

LCHF and Cholesterol Profile

You may have come across the talks by Ivor Cummings on cholesterol. Ivor is a chemical engineer by trade and after receiving some personal alarming blood readings he decided to drill down into the meaning of what his readings actually meant. Applying his engineering rigour to the problem he quickly discovered that the emperor was wearing no clothes or the doctor in this case. I came across another engineer Dave Feldman, that has also gone into even more detail to extrapolate the real relationships between what we eat and how it effects cholesterol and associated lipid readings. It is a real beauty of a presentation which if you are new to the subject might take more than one listening. You can also easily replicate the experiment yourself, in fact he is appealing for people to try it and log their results on his blog.

Sugar and Oil

The two things that have exploded in consumption along side the widespread development of heart disease are the consumption of these two food sources. We were all advised by the diet guideline experts in the 70’s to switch from saturated fat to vegetable oils and veg’ oil even today is common place in UK kitchens. Restaurants not only use it but to save money only change it when its oxidized to exhaustion. This study, until recently kept hidden, makes you wonder how we ever got on this path. It also suggests that what we eat is a bigger threat than cholesterol per se.

A Must Watch

During the Vietnam war the US realized that they could create more damage to the opposition forces by inventing a bullet that would maim opposing soldiers rather than kill them. Why was this and what does it have to do with the staggering increase in Autism we have experience in just one generation. Mercola talks this interview up in the introduction but he is not hyping, its simply a must watch, pass it on to others