“Everyone goes home”. It’s a saying among firefighters that implies “I’m going to do whatever it takes to get you home safe". Simply put, I’ve got your back and I trust that you’ve got mine.
The firefighters of Engine 2 in Austin, Texas were a close and competitive crew, always trying to one up each other with tests of strength, intellect, and often, down right silliness.
One night, when a debate about health broke out, a wager was made to see who among them had the lowest cholesterol.
When the results returned there was one clear winner and one noticeable outlier.
Cadet James Rae ranked highest on the list with a total cholesterol of 344, more than twice the normal level.
James was only 33, married with two young kids, and a family history notable for his father and grandfather both dying from a heart attack at the age 52.
It turns out the number one killer of firefighters is not fires, it’s heart disease and the leading cause of heart disease is high cholesterol.
James’ fellow firefighters weren’t having it. So they did what heroic individuals do, they rallied together and hatched a plan to save James’ life.
To do so, they looked at who won the bet and they essentially made the winners diet the diet of the entire firehouse for breakfast, lunch, and dinner every day.
After just three weeks on the new diet, James’ cholesterol dropped by 148 points. A statin, or cholesterol drug, typically lowers your level by 30%.1 James’ dropped by twice that.
The cholesterol-lowering diet the firefighters employed was no fluke. It’s an evidence-based strategy backed by research from the American Heart Association.2
In just a few months, James’s cholesterol was in the green zone. He lost weight, put on lean muscle, and got off most of his meds. Fast forward fifteen years later, James is still at Engine #2 and as healthy as ever.
Everyone goes home.
Welcome to the Better Medicine Podcast. I’m Dr. David Zodda and my job is to help you live a better life. I do this by digging into the most up to date research in health, fitness, and nutrition to uncover what actually works. I then share actionable insights and strategies so that you can get more of what works into your life.
What sets our platform apart from the others is that all of our content is referenced, evidence-based, and peer-reviewed by some of the most forward thinking leaders in medicine and nutrition.
If you’re among the nearly half of Americans on the high cholesterol list or if you never want to end up on that list, today's episode is for you.
In Act 1 of today's podcast, we’re going to get a better understanding of what cholesterol is, where it comes from, why our bodies need it, and what happens when our levels get too high. We’ll cover why the dogma of good and bad cholesterol is flawed and discuss two essential cholesterol labs that are a better predictor of your heart health.
In Act 2, I share with you the science-backed approach the firefighters at Engine #2 used to lower their cholesterol, lose weight, and improve their overall health. And we’ll wrap things up with five nutritional strategies to get your cholesterol right where it needs to be.
When it comes to your health and wellbeing, you have great agency and control. And when you combine that agency with evidence, you can do great things. Welcome to Better Medicine.
Act 1: What Works
Cholesterol often gets a bad wrap but without cholesterol we wouldn't exist. Cholesterol is produced by every cell in our body.3 They make it to stabilize their cell membrane. You can think of cholesterol as the rebar that reinforces the foundation of a home.
Beyond cell structure, our bodies also use cholesterol to make things like vitamin D, bile to help us digest fat, and hormones like estrogen and testosterone.4
Cholesterol is a lipid, basically a fatty molecule. And, while most of the cholesterol circulating in our body right now was produced by your liver, about 20% of our cholesterol comes from the food we eat.5
When James Rae’s cholesterol went north of 300, his body couldn’t clear the excess and over time, it found a new home inside the lining of his artery walls..
Once inside our blood vessels, cholesterol wreaks havoc. It turns into plaques causing vessels to narrow and stiffen.
When plaques form in the arteries of our heart they can cause a heart attack. And, should any of these plaques that break off, they can travel to the brain and cause a stroke.6
The bottom line is the lower your cholesterol, the lower your risk of heart attack and stroke.
When the firefighters at Engine #2 had their cholesterol checked they essentially got what's called a lipid panel.
You’ve likely heard of HDL, high-density lipoprotein, and LDL low density lipoprotein. These are carrier proteins that transport cholesterol in our body.
The key difference between these two proteins is their job. LDL takes cholesterol from our liver and delivers it to cells all over our body while HDL picks up excess cholesterol and brings it back to the liver.7
This is why for decades, we have all been taught that LDL is “bad” because it takes cholesterol from the liver and deposits it in the walls of our arteries and HDL is “good” because it picks up excess cholesterol and brings it back to our liver.
Simple, right? But what if that wasn’t the whole story?
A few years ago a cardiologist in Chicago noticed something strange happening. When he looked at all the patients presenting to his hospital with a heart attack he discovered that more than half of them had normal levels of LDL cholesterol.8
But wait, how could someone with a normal LDL have a heart attack?
Well, it turns out that there are a lot of lipoproteins circulating in our blood beyond LDL. There’s IDL, VLDL, triglycerides and at least a dozen others. So when we measure just our LDL we’re missing all of these other quote unquote bad lipids.
Even when we measure our total cholesterol, like James did, we’re only getting a small picture of the cholesterol circulating in our bodies. But there’s good news.
There is a small protein found on the outside of all of these harmful lipoproteins that gives us a much more accurate number of our body’s cholesterol. It’s called apolipoprotein B or ApoB for short.9
When you test for ApoB, you not only get the number of LDL particles, you get the number of all of your potentially harmful lipoproteins thus giving you a much better picture of your overall cardiovascular health.10
ApoB is a better risk predictor than the traditional lipid panel but there’s a problem, very few physicians are testing for it.
There are several reasons for this. Clinicians may not be aware of it, insurance may not cover it, and while nearly all labs can run lipid panels, not every lab has the capability of running an apoB score.
This needs to change. And until it does, we can advance that change by making ourselves more aware and asking our physician to test for ApoB at our next doctor's visit.
The goal should be to get you ApoB as low as possible. Most guidelines suggest less than 60mg/dL but the lower the better.11
It turns out there’s one other lipid at play that has a major role in atherosclerosis that’s also not routinely being tested for. It’s called lipoprotein(a), pronounced “LP little a”.
Lp(a) is another cholesterol particle but this one is unique. We get Lp(a) from our parents, it’s genetic. It’s passed on by what’s called dominant inheritance, meaning if just one of your parents has it, there’s a 50% chance you have it as well.
About one in five people have Lp(a). The problem is that Lp(a) is much worse than LDL. It’s more inflammatory, it promotes clot formation, and those that have it are at higher risk for heart attack and stroke.12
Lp(a) concentrations can be found in almost anyone but is two to three times more prevalent among people of African descent.13
The bummer is that LPa can’t be reduced with the usual things we do to lower our cholesterol. Diet and exercise have no effect on Lp(a). Even cholesterol lowering medications like statins have limited effect.
For Lp(a) a normal test result is <30mg/dL (<75nmol/L). Like ApoB, it’s not included in the standard lipid panel, so you have to ask your doc to check for it.
I got mine checked and, to my surprise and dismay, it was high.
While I’m no firefighter, I’ve been plant-based for twenty five years. I podium at triathlons. I’m the weirdo who brings the kale salad to work. And despite all this my Lp(a) was twice the normal value.
So what did I do? I collected my thoughts and tried not to freak out. I did some research. I spoke with my family. And I made this podcast so that all of you could be more informed and go out and get tested.
While there are some promising results with the use of flaxseed to lower Lp(a), there’s no supplement or medication solution here yet.14 Ultimately, my main strategy is to get my ApoB level as low as possible.
Remember all of those potentially harmful lipoproteins including Lp(a) use ApoB as a carrier. Reducing my carrier protein levels reduces my cholesterol, and thus reduces my overall risk of cardiovascular disease.
Okay, so let’s recap.
Our body needs cholesterol, the majority of which comes from our liver and about 20% from our diet. Cholesterol is transported in our blood vessels using lipoproteins and when our cholesterol gets too high the excess cholesterol gets deposited in the walls of our arteries causing narrowing and plaques which lead to heart attack and stroke.
We can use values like ApoB and Lp(a) to assess our risk profile for heart disease and our goal should be to get these two numbers down as low as possible.
But how do we do that? How can we actually lower our cholesterol? How did James Rae drop his numbers by more than half in less than a month? We lay out a blueprint for optimizing your cholesterol in Act 2 of today's episode.
But just before we go there, I just want to pause for a moment and say thank you for listening to the Better Medicine Podcast. Our goal here is simple. We research what works so that you can get more of what works into your life.
Please take a moment and go to our website BetterMedicine.com and subscribe to our monthly newsletter. It’s free and frankly, it’s the best way for us to stay in touch. There you can find links to all of our podcasts, show notes, as well as discounts from our sponsors.
And if you’re interested in working to improve your own personal health, you can sign up for personalized coaching sessions with me. As a professional health and wellness coach, I work one-on-one with you to help you explore and enhance your own personal nutrition and fitness goals to get you living and feeling your very best. Sign up today at BetterMedicine.com and thanks for listening.
Act 2: How to Get More of What Works Into Your Life
The cholesterol-lowering diet the firefighters used is actually a strategy backed by research from the American Heart Association.2 It’s based on the portfolio diet which has been shown to lower cholesterol as much as a statin. It has four main features.
Strategy #1: Perfect Your Protein
Now look, firefighters don’t mess around when it comes to their protein but what if the type of protein they were eating was driving up their cholesterol?
Protein comes in a lot of different forms. The protein the firefighters were getting primarily came from meat like beef, chicken, pork, and dairy.
While these foods are high in protein they’re also quite high in saturated fats. And it turns out that it’s the saturated fat in these foods that was fueling their cholesterol.
You’ll remember from Act 1 that HDL particles carry our excess cholesterol back to the liver to take it out of circulation. HDL attaches to tiny cholesterol receptors on our liver to deposit the cholesterol.
When our body’s saturated fat levels increase, say after eating meat or dairy, those saturated fats turn off the cholesterol receptors on our liver. The result, HDL can’t return the excess cholesterol and it in turn builds up in our circulation and eventually in our blood vessels.15
Plant-based proteins have the opposite effect. Because they lack saturated fat, plant-based proteins actually increase the sensitivity of the cholesterol receptors on our liver.16 This helps HDL deposit the excess cholesterol it’s picked up, thus lowering your cholesterol.17
But how effective can plant-based proteins be at lowering our cholesterol?
An Oxford researcher recently tested that very question. He gathered a group of individuals with high cholesterol and split them into groups, one group went on a plant-based protein diet. The other group went on a standard diet that included meat and dairy, plus a cholesterol lowering statin.
In just four weeks both the statin group and the plant-based group saw their cholesterol go down by about 30%. Just by switching to a plant-based protein diet researchers were able to yield the same cholesterol lowering results as medication.18
Since that landmark study was completed, additional studies have confirmed its findings. The latest showing that reducing meat consumption and switching to plant-based proteins reduces your risk of heart attack and stroke by double digits.2
And don’t believe the hype that you need to eat meat to get enough protein. Plant protein is equally as effective as animal protein for building and maintaining strength and lean muscle.19
So how can you get more plant-based proteins into your diet? Replace dairy products like milk and yogurt with soy-based versions like soy milk. Snack on edamame and hummus. And swap out meat protein for plant-protein with beans, lentils, chickpeas, tofu, and tempeh.
Look, I know it sounds intimidating to get rid of some of your tried and true favorite meals. And this wasn’t easy for me either. I grew up in a family where meat and dairy were a part of every meal.
My strategy was to make small daily changes and see how they made me feel. This doesn’t have to be an all or nothing effort. Making even a few small changes to where you source your protein can make a big difference.
Strategy #2: OG Grains
A study published in the highly-prestigious medical journal The Lancet about fifty years ago looked at the cholesterol lowering properties of, wait for it, oatmeal. The study simply added oats to the diet of individuals and after just three weeks their cholesterol dropped by more than 10%.20
Over the years, clinical study after study has found that ancient grains like oats was so good for you that in 1997 the FDA certified that certain grains, including oats, lowered not just your cholesterol but your risk of death from cardiovascular disease.21
Your oatmeal is legit FDA approved!
To understand why grains like oats lower our cholesterol we need a quick anatomy lesson.
Our liver uses our body’s stores of cholesterol to make bile to help us digest fatty foods.
Oats contain a unique soluble fiber called beta-glucan which absolutely loves bile.
When we eat oat containing products like oatmeal, the beta-glucan in the oats binds to the bile circulating in our bloodstream and enhances its removal.
As your bile levels plummet, your liver has no choice but to use up more and more of your body’s cholesterol to make more bile thus lowering the amount of total cholesterol in your blood.
So essentially, the more oats, the less bile, the lower your cholesterol. But not all oats are the same.
Processing oats alter the effectiveness of beta-glucan and reduce its ability to lower cholesterol. It’s therefore best to reach for steel cut or rolled “old fashioned” oats rather than quick or instant oats as these are more processed and less effective.
And it’s not just oatmeal that has the cholesterol lowering magic of beta-glucan. Quinoa, barley, and nutritional yeast are all high in beta-glucan.
At the firehouse this looked like overnight oats for breakfast, baked quinoa chips and guac for lunch, barley risotto for dinner, and a sprinkle of nutritional yeast on pretty much everything.
Strategy #3: Go Nuts
For years, physicians have been telling folks with high cholesterol to go on a low-fat diet primarily because of the unwanted effects of saturated fat.
But there are other fats out there. And it turns out, most monounsaturated and polyunsaturated fats actually lower your cholesterol.
These types of fats are found in walnuts, almonds, pistachios, peanuts, and cashews, seeds like sunflower and chia, and olive oil.
One study showed that just one to two handfuls of nuts a day not only lowered your cholesterol but cut the risk of having a heart attack in half.23
Plants have another cool way to lower our cholesterol.
Plants cell membranes are made of phytosterols and it just so happens that phytosterols and cholesterol use the same transport system in our bodies.
Therefore when we eat plant-based foods like fruits, vegetables, nuts, and seeds the plant phytosterols compete for the same transporters as cholesterol. This tanks cholesterol absorption and therefore reduces its amount in our body.24
At engine company #2, bowls of nuts began appearing all over the firehouse. They were added to everything from salads, to cereals, to card night snacks.
The key to optimizing a new habit is to make it easy. Nuts out of sight in a container in the pantry, no one is going to eat those, but nuts that are out on the kitchen counter and dinner table are far more likely to be consumed.
Strategy #4: Fix Your Fiber
It seems like everyone is talking about the gut microbiome lately but what is it and how is it connected to lowering your cholesterol?
Right now, within our intestines, there are roughly 40 trillion bacteria. Now don’t freak out. These bacteria are here to help us. They digest food, metabolize medications, and protect us from disease.
Well, it turns out that the bacteria in our gut microbiome absolutely love fiber.
When we eat fibrous foods like beans, lentils, fruits, and vegetables, the bacteria in our gut microbiome convert this fiber into a gel-like substance. These little fibrous gel-globs have a certain knack for trapping excess cholesterol floating around in our circulation and reducing its absorption.
Fiber has also been shown to trap certain toxins and carcinogens. This is why increased dietary fiber has been shown to not just lower cholesterol but lower blood pressure, blood sugar, stroke, heart disease, even rates of breast and colon cancer.25
You can increase your fiber either by eating more plant based foods or by taking a supplement. One study found that when individuals took psyllium, basically Metamucil, it reduced their LDL as much as taking a statin.26
So what did this fiber fix look like in the firehouse?
Breakfast went from bacon and eggs to oatmeal and blueberries. Lunch went from deli meat sandwiches to avocado toast on whole wheat bread, and dinners transformed into stir fries, veggie burgers, and black bean sweet potato burritos.
In just three weeks, following these four strategies, James Rae’s cholesterol dropped 148 points. Beyond that, the firefighters at Engine #2 essentially leaned into the “everyone goes home” strategy and in doing so, created a culture around healthy eating that supported everyone.
So let's sum it all up.
We’ve shown that cholesterol is essential. It is the building blocks of hormones, vitamins, and is found in every cell in our body.
But, what serves us also can harm us when out of balance as excess cholesterol leads to plaque formation thus increasing our odds of stroke and heart attack.
We covered the importance of getting our cholesterol checked each year and in particular getting our ApoB and LP(a) levels checked as these are much better indicators for our overall risk of cardiovascular disease.
And so I invite you to follow James’ lead and follow his four cholesterol lowering strategies.
#1 Replace the meat and dairy protein with plant-based proteins like beans, lentils, chickpeas, and soy. These foods upregulate LDL receptors on your liver and help lower your cholesterol.
#2 Make a few meals every week using OG grains like oatmeal, barley, and quinoa. They are literally FDA approved for reducing your risk of heart attack and stroke.
#3 Grab two handfuls of lipid-lowering almonds, walnuts, chia, and flax seeds every day and keep them out on the counter to make them more likely to be eaten.
#4 Fix your fiber by simply adding more fruits and vegetables to your diet. Your future self will thank you for it.
When it comes to optimizing your cholesterol, it doesn’t have to be an all or nothing strategy.
Change doesn’t have to begin with a grand gesture. It often starts quietly — a healthy change to your morning routine, a walk after dinner, a decision to listen to what your body is trying to tell you.
Those small choices are powerful. They build momentum, they build confidence, and over time, they build health.
Thank you for listening to the Better Medicine Podcast where we research what works so that you can get more of what works into your life.
I’d like to thank Dr. Adam Raskin, board certified cardiologist for peer-reviewing the content for this episode.
I truly hope you enjoyed our conversation today. To learn more about today's show, including links, resources, coaching, and references to everything discussed go to BetterMedicine.com
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References
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