How to Raise Your Cardioprotective HDL [Rev. 12-22-11, 04-18-12, 05-17-16]

Note: Revisions or additions are in red  font.

What is HDL?

HDL stands for high density lipoprotein and its importance in being a key player in preventing atherosclerosis (artery clogging) is more and more evident.[1],[16] It has even been seen that when LDL, (the ‘bad' or 'lousy' cholesterol), is very low, it is the HDL which is the deciding parameter on whether or not heart attacks (and other events) occur.[2] I, for one, am very insistent with my patients in raising this factor.

How does it work?

HDL promotes the mobilization and clearance of excess cholesterol via the series of reactions collectively termed ‘‘reverse cholesterol transport.’’[3] This is where cholesterol in the wall of the artery (and elsewhere) is removed before it is incorporated into the wall (or elsewhere) pathologically and irreversibly (it is a normal/natural constituent of cell structures and substances). Another mechanism cited is that HDL possesses many antioxidant capabilities, and thereby pre-empting the oxidation reactions inherent in development of atherosclerosis.[3] Another mechanism is HDL stimulates endothelial nitric oxide production and thence increases vasodilatation (opening up of blood vessels) and heart muscle blood flow. HDL also significantly impacts the capacity of inflammatory white blood cells to enter and take up residence in the sub-endothelial spaces of arteries.[4][5] This last factor is a probable player in removal of cholesterol molecules by engulfing them and removing them to safer dispositions.

My personal conviction is that the first phenomenon of reverse cholesterol transport is the most important one. There are other described mechanisms outlined in the figure which I won't go into.[6]

Conceptually from Figure 1 in reference [6]

The actual steps to take for increasing HDL are as follows:

• Increase healthy oils intake - olive oil, fish oil, coconut oil, butter and animal fats. Concerning the last two it applies to organic products and not those which come from animals enhanced by bovine growth hormones and whose products will contain supernatural levels of IGF (such as present in the USA). This last may be the factor which increases heart related events occurring in those consuming relatively high levels of animal fats in some people in the USA.[7] I say this because there is solid evidence that fat intake of animal origin is associated with lower cardiac mortality compared to the USA as in the French population[8] and the Eskimos[9]. Their food products are organic predominately. I (personally), target a 45% calorie quota for fats and oils of an overall calorie intake, and I emphasize the organic or natural status of said  fats. 45% is mid-way between the French and Eskimos.[8],[9] Here I would like to add that I use calories as a practical measure only, as the scientific basis of their translation into body energy is very shaky at this point in time (6-17-12, 5-17-16). 
• Increase low glycemic index foods – in other words avoid sugars (sucrose and high fructose corn syrup), and foods containing starch. This may also be described as a low-carbohydrate diet, with a relatively high consumption of fat and protein.[10]
• Fatty tissue weight loss if needed by controlling overall calorie intake as follows: if the person is at a healthy body mass index (BMI) then intake should be equal to calorie expenditure. If the BMI is high resulting from high body fat then intake should be less than expenditure. If the BMI is low then one should increase overall calorie intake.
• Engage in more aerobic exercise regularly, daily.[16]
• Tobacco and smoking cessation if applicable.[11],[16]
• Ensure intake of good quality protein (preferably animal origin that hasn’t been treated with bovine growth hormone – BST). Target a minimum of 1 gram per kilo body weight per day. This is because protein is a building block for HDL. As mentioned previously HDL stands for high density lipoprotein.
• With your physician’s consent and instruction – take niacin 500 – 2000 mg in the morning depending on how low your HDL is. This is also known as nicotinic acid. Be ready for the flushing and itching. This will occur 5 – 30 minutes after ingestion and happens in most people. Lasts around 10 – 45 minutes. Use the immediate release form. It is worth the flush. This medicine (which is also a vitamin) has been shown to decrease heart attack incidence. [6],[12],[13],[14],[15]
• Take vitamin C (ascorbic acid) as a supplement orally to the tune of 250 mg daily.[11],[17]
• Other agents are available that may raise HDL such as statins (unusually), fibrates and more novel agents in the pipe line[3]. That being said I am not too enthusiastic about all cholesterol ester transport protein inhibitors (CETP-I).[18] My lack of enthusiasm here is because of their mechanism of action. They work by essentially preventing HDL from reaching its end-point target environment, and as such will increase the level in the blood, but won't remove LDL. Bad idea. It astounds me how much money is being/was spent on developing such a non-nonsensical drug. 
• Of all current options, nicotinic acid is not only the most potent agent for raising HDL-C but is also effective in reducing key atherogenic lipid components including triglyceride-rich lipoproteins (mainly very low-density lipoproteins [VLDL] and VLDL remnants), LDL-C, and lipoprotein(a). The European Consensus Panel recommends that the minimum target for HDL-C should be 40 mg/dL (1.03 mmol/L).[6] I prefer a target of 60 mg/dL or higher.

References:
[1] P Natarajan, KK Ray, CP Cannon (2010) High-density lipoprotein and coronary heart disease: current and future therapies. J Am Coll Cardiol 55: 1283-1299. Doi:10.1016/j.jacc.2010.01.008.
[2] P Barter, AM Gotto, JC LaRosa, J Maroni, M Szarek, SM Grundy et alHDL Cholesterol, Very Low Levels of LDL Cholesterol, and Cardiovascular Events. N Engl J Med 357: 1301-1310.
[3] PT Peter (2009) Novel Therapies for Increasing Serum Levels of HDL. Endocrinology and metabolism clinics of North America 38: 151-170.
[4] X Li (2000) Protective effect of high density lipoprotein on endothelium-dependent vasodilatation. Int J Cardiol 73: 231 236. Doi:10.1016/S0167-5273(00)00221-7.
[5] B Levkau, S Hermann, G Theilmeier, M van der Giet, J Chun, O Schober et al (2004) High-Density Lipoprotein Stimulates Myocardial Perfusion In Vivo. Circulation 110: 3355-3359. Doi:10.1161/01.CIR.0000147827.43912.AE.
[6] MJ Chapman, G Assmann, JC Fruchart, J Shepherd, C Sirtori, European Consensus Panel on HDL-C (2004) Raising high-density lipoprotein cholesterol with reduction of cardiovascular risk: the role of nicotinic acid--a position paper developed by the European Consensus Panel on HDL-C. Curr Med Res Opin 20: 1253-1268. Doi:10.1185/030079904125004402.
[7] TT Fung, RM van Dam, SE Hankinson, M Stampfer, WC Willett, FB Hu Low-Carbohydrate Diets and All-Cause and Cause-Specific Mortality. Annals of Internal Medicine 153: 289-298. Doi:10.1059/0003-4819-153-5-201009070-00003.
[8] MH Criqui, BL Ringel (1994) Does diet or alcohol explain the French paradox? Lancet 344: 1719-1723.
[9] H Bang, J Dyerberg, N Hjøorne (1976) The composition of food consumed by Greenland Eskimos. Acta Med Scand 200: 69-73.
[10] GD Foster, HR Wyatt, JO Hill, AP Makris, DL Rosenbaum, C Brill et al (2010) Weight and Metabolic Outcomes After 2 Years on a Low-Carbohydrate Versus Low-Fat Diet. Annals of Internal Medicine 153: 147-157. Doi:10.1059/0003-4819-153-3-201008030-00005.
[11] J Hallfrisch, VN Singh, DC Muller, H Baldwin, ME Bannon, R Andres (1994) High plasma vitamin C associated with high plasma HDL- and HDL2 cholesterol. Am J Clin Nutr 60: 100-105.
[12] PL Canner, KG Berge, NK Wenger, J Stamler, L Friedman, RJ Prineas et al (1986) Fifteen year mortality in Coronary Drug Project patients: long-term benefit with niacin. Journal of the American College of Cardiology 8: 1245-1255.
[13] K. G. Berge1 Contact Information,P.L.Canner2 and Coronary Drug Project Research Group, (1) Mayo Clinic, 55905 Rochester, Minnesota,USA, (2) Maryland Medical Research Institute, Baltimore, Maryland,USA (1991) Coronary drug project: Experience with niacin. European Journal of Clinical Pharmacology: S49-S51; S49.
[14] JB Segal, J Eng, LJ Tamariz, EB Bass (2007) Review of the Evidence on Diagnosis of Deep Venous Thrombosis and Pulmonary Embolism. Ann Fam Med 5: 63-73. Doi:10.1370/afm.648.
[15] Clofibrate and niacin in coronary heart disease. (1975) JAMA 231: 360-381.
[16] Anonymous Association of High-Density Lipoprotein Cholesterol With Incident Cardiovascular Events in Women, by Low-Density Lipoprotein Cholesterol and Apolipoprotein B100 Levels . http://annals.org/content/155/11/742.abstract. Accessed 12/22/2011 2011. 

[17] Jacques, PF. “Ascorbic acid, HDL, and total plasma cholesterol in the elderly.” Journal Of The American College Of Nutrition, v. 6 issue 2, 1987, p. 169-174.

[18] J Poss, M Bohm, U Laufs (2010) HDL and CETP in atherogenesis. Dtsch Med Wochenschr 135: 188-192. Doi:10.1055/s-0030-1247862.

If You Eat Too Late At Night Does Your Body Repair Stop

My friend at Anti-Aging Games, Elizabeth Amini had a another question for me:

Is it true that your body repairs one organ at a time every hour at night and if you eat late, your body chooses to focus on digestion instead of repairs during that time period and whatever organ is supposed to be repaired isn't during that time?  It seems suspicious that the body works on an arbitrary time slot that humans sliced up the day by.  I've heard it from both Eastern and Western doctors.

Answer to first part of question:

The body in all its tissues (and its organ units) is in continual repair, night and day. The extent of repair and who is getting the most attention will vary with the extent of damage, exhaustion or use of that specific tissue or organ. All of the processes of repair will depend on the signals emanating from the tissues (organs) signaling the need. This will be in the form of chemicals (such as lactic acid or substance P for example), or neurologic signals. Other factors are the availability of the building blocks (such as amino acids), assisting substances (such as vitamin C), energy hormones (such as growth hormone), building hormones (again such as growth hormone), fuel for energy (fatty acids) and appropriate surrounding temperature. A major factor is whether or not that tissue is being involved in full scale repair or not is if said tissue is in use or not. When the tissue is active then the amount of repair is less and vice versa.

Since most tissues and organs are less active when a person is sleeping, then a large part of repair of all tissues will occur during the person’s sleep cycle. In addition, there is escalation of growth hormone secretion when the eyes are closed (especially in adults), which is a major player in repair. Therefore, sleep truly is ‘renovation time’.

The premise that the ‘body repairs one organ at a time every hour at night’, to me is without scientific basis and I don't think that any one organ has a specific hour to be repaired in. It is a continuous process.

Answer to second part of question:

By eating late the repair of the gastrointestinal tract is probably delayed because of it being busy with digestion and absorption. Some of the energy resources required for the digestion and absorption which would otherwise be dedicated to repair or replenishment may be diverted away from the repair arena. This would especially be true if the meal size is large. To what extent this occurs isn't known to me, but I seriously doubt that it is as absolute as described in the question. As such it is my conviction that it is healthier to have frequent small meals instead of large ones to have a continuous low drain on energy resources needed for repair, while at the same time having a continuous influx of building blocks and energy resources. This concept, along with exercise, is capitalized upon (knowingly or otherwise), by Bill Phillips, in his strategy for getting healthy in his book, Body-for-LIFE: 12 Weeks to Mental and Physical Strength (1999). So I would say it is okay to eat late as long as the meal size is small.

Does Alkalinizing The Body Through Ingesting Food and Fluids That ‘Alkalinize’ The Body Have a Positive Impact on Health?

My friend at Anti-Aging Games, Elizabeth Amini (Founder & CEO, Anti-Aging Games, LLC) had a question for me:

Does alkalinizing the body through ingesting food and fluids that ‘alkalinize’ the body have a positive impact on health?

Answer:

I doubt it very much. The body’s pH (acidity/alkalinity index), and here referring to blood and tissue fluids, is tightly regulated by among other organ systems, the lungs and kidneys. These two systems do that in a very magnificent synchronized fashion maintaining this tight range through multiple redundant backup tactics.
The pH of blood should be 7.35 to 7.45 which is truly on the alkaline side, but this shouldn’t translate into drinking or eating alkaline is better for us. I believe this is trying to fine-tune things artificially too much to the exclusion of highly important nutrients such as healthy proteins.
Also in-taking a consistently alkaline fluid or solid would put a burden on the kidneys to counter balance excess alkalinity. It would also trend our breathing to be slower so as to retain more carbon dioxide, especially if the kidneys aren't getting sufficient water (whose pH by the way is 7.0).
In conclusion I would say: eat healthy protein sufficiently (not less than 70 grams per day for a healthy adult), eat healthy fats (hormone free, and non-synthetic) sufficiently to the tune of 40-45% of the conventionally measured calorie intake, unlimited vegetables (preferably not genetically modified and also grown in fertile ground that hasn’t been exhausted of its minerals), and use fruits as a dessert. No refined sugars at all and keep refined carbohydrates (pasta, lasagna, breads, etc.) below 100 grams per day. Drink enough refined-sugar-free fluids to ensure a urine color that is very light yellow with a daily minimum of 3 urinary bladder full micturitions (urinations).

The websites you had referred to are too unscientific in their presumptions.

How much fat to eat to absorb vitamin D and how many total calories per day to lose weight. (To Anonymous)

In reply to your lovely questions I think it necessary to understand the premise of calorie (calorie=Kilocalorie) content of food: food calorie content is usually assessed by totaling the calories of the individual nutrients of a given food. For example the calorie production of protein is assessed to be 4 calories per gram, and that of fat as 9 calories per gram, and carbohydrates 4 calories per gram.[Food Energy [1]] These estimates for the individual food nutrients are done by direct calorimetry as follows: 

Merck Manual - Home Edition [2]

This to me this is a very imprecise, unscientific way of estimating calorie content in food as it translates into energy or fat storage for the human body. The body is not a bomb calorimeter and as such translating or equating 1 gram of fat to 9 Calories of energy that will be stored as fat is pretty naive (on the part of the authorities, scientific or governmental). The support for my statement above is evidenced by more than one study, but my favorite is in a study published in the Annals of Internal Medicine in 2010 where it was clearly seen that successful weight loss can be achieved with either a low-fat low-calorie or low-carbohydrate unlimited calorie diet when coupled with behavioral treatment.[3] Focus here on unlimited calorie intake of fat and protein. Another study in support of my statement included the Atkins diet where it was seen: women assigned to follow the Atkins diet, which had the lowest carbohydrate intake, lost more weight and experienced more favorable overall metabolic effects at 12 months than women assigned to follow the Zone, Ornish, or LEARN diets.[4] Therefore a low-carbohydrate, high-protein, high-fat diet, with good amounts of vegetables and fruit is in my opinion the best recommendation for weight loss. That being said the fats must be hormone free (rBST), and non synthetic. (I am not a full supporter of the Atkins diet because of its exclusion in certain phases of all forms of carbohydrate including vegetables and fruit, and the other part is not addressing the kind of fats allowed that may or may not include synthetic fats and fats coming from animals treated with rBST. To be fair though the latter happened more than 2 decades after his initial publication of the Atkins Diet Revolution. I admire the gentleman immensely for breaking the ‘Fat Barrier’.)
My direct message to Anonymous: Do not count calories to lose weight but AVOID refined carbohydrates (refined sugars, flour, rice, potatoes, etc.). Feel free to have unlimited amounts of healthy oils and a minimum amount of protein (hormone free) of 80 grams per day. This can translate into eating 1-2 pieces of fried chicken daily or equivalent (as long as there are no mashed potatoes, breads, pasta, lasagna, etc.) and this should be amply sufficient for absorption of your vitamin D supplement. Additionally you may have unlimited amounts of vegetables and use fruit as your dessert. Please continue the exercise and target sleeping 7.5 to 8.5 hours per 24 hour cycle.
I do realize that the calorie count concept will be hard to get rid of but the science just isn’t in favor of limiting fats and protein. 
 Also an opinion of mine not yet proven: I fear low fat is more in favor of cancer evolution than not, unless the fat intake has come from animals treated with rBST. I fear the last will contain said hormone (in meats) or higher levels of insulin growth factors (in milk and its products) both which will encourage increase in cell size and number artificially. This seems to me to be dangerous ground to tread.
I hope this answers your questions. Stay the course of health, it is very very worth it.

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References:
[1] http://en.wikipedia.org/wiki/Food_energy
[2] http://www.merckmanuals.com/home/disorders_of_nutrition/overview_of_nutrition/calories.html
[3] GD Foster, HR Wyatt, JO Hill, AP Makris, DL Rosenbaum, C Brill et al (2010) Weight and Metabolic Outcomes After 2 Years on a Low-Carbohydrate Versus Low-Fat Diet. Annals of Internal Medicine 153: 147-157. Doi:10.1059/0003-4819-153-3-201008030-00005.
[4] CD Gardner, A Kiazand, S Alhassan, S Kim, RS Stafford, RR Balise et al (2007) Comparison of the Atkins, Zone, Ornish, and LEARN Diets for Change in Weight and Related Risk Factors Among Overweight Premenopausal Women: The A TO Z Weight Loss Study: A Randomized Trial. JAMA 297: 969-977. Doi:10.1001/jama.297.9.969.