Friday, June 10, 2016

Understanding The Liver and Cholesterol

And come to the liver, one of my favorite organs. Certainly the heart, the brain, and the immune system get more play in the popular imagination than the liver, but that's only because the liver is so misunderstood. Next to the skin, the liver is the largest organ in the body. In many ways, it is the most important organ, and the last to be considered when it comes to health. In addition to being large, the liver is also a complicated organ involved in at least 200 separate functions. Generally speaking, the liver performs a vital role in regulating, synthesizing, storing, secreting, transforming, and breaking down many different substances in the body. In this issue, we explore the anatomy and physiology of the liver in detail from a natural health perspective, and conclude with a discussion of how the body regulates cholesterol and why statin drugs may not be all that doctors promote.

 As I mentioned above, the liver is the heaviest and largest gland inside the body, weighing in at about 3 pounds. Only your skin (also a single functioning organ) is larger. Your liver occupies almost the entire right upper quadrant of the abdominal cavity. (Remember that in virtually all medical diagrams, right and left are reversed.) It nestles up against the diaphragm on the top and against the ribs on the right -- stretching across the body, almost touching ribs on the left. Thus, barring extreme trauma such as bullet wounds and automobile accidents (or if it is not enlarged), it is fully protected -- a testament to how important the body considers the organ.

 Physically, it is divided into four lobes, a large right and a small left lobe. Nestled between those two lobes are two less easily visible lobes, the quadrate lobe sitting on top and the caudate lobe sitting just underneath and extending to the bottom of the liver.

 Obviously, a three pound organ cannot just "hang" in the abdominal cavity. It needs to be secured.  And in fact, it is suspended from the back of the diaphragm by two ligaments, the falciform and the suspensory ligaments. The falciform ligament in particular runs up through the entire liver, dividing the left and right lobes before attaching to the diaphragm. There is one other interesting note about the falciform ligament. The umbilical vein, when you are inside the womb, runs from the umbilical cord up between the left and right lobes of the liver. Within a week of birth, that vein is completely obliterated and replaced by the fibrous cord known as the falciform ligament.

 The liver has a reserve capacity of some 50-80%. That means you can destroy up to 80 percent (and in some cases possibly even more) of the liver's function and have no demonstrable negative symptoms. And as amazing as that is, it's not the most amazing part. As I have mentioned frequently over the years when talking about detoxing the liver, the liver is one of the few human organs that can regenerate itself. It can actually regenerate (in a matter of weeks) up to an 80% loss of tissue. Once regenerated, it will fill the same space it occupied before, and will take roughly the same shape as before. And when it's done regenerating, it stops! Though it grows faster than any cancer known to man, its regeneration does not become malignant, and the liver will stop growth at approximately its normal size. This is particularly useful after trauma such as an automobile accident that has damaged part of the liver. The damaged or diseased tissue can be removed by the surgeon with no loss of liver function, and in a matter of a few weeks, the liver will have regenerated all of its lost tissue. You've gotta love this stuff!
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Familial Hypercholesterolemia: How to Lower Your Elevated LDL Cholesterol

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Cholesterol is naturally produced by your body and is essential to its function throughout your everyday life. However, excessively high levels of cholesterol—in particular, LDL cholesterol— are bad and can lead to serious health problems such as clogged arteries, heart disease, and stroke.
What is LDL Cholesterol?
LDL stands for Low-Density Lipoproteins. This type of cholesterol is produced by the liver and is instrumental in the creation of cell walls, hormones, and digestive juices. However, when your LDL level is high, it can start to form a plaque-like substance on the walls of your cardiovascular system, blocking the natural flow of blood and leaving you at severe risk for heart attack and stroke. Put simply, LDL is the bad kind of cholesterol. But fear not – there are several ways in which you can lower your LDL cholesterol and encourage the development of High-Density Lipoproteins (good cholesterol), which actually function to limit the level of LDL cholesterol in your system.
Diet
Altering your diet is the easiest way to lower your elevated LDL cholesterol, and should be your first course of action, as every cholesterol-lowering strategy starts with your dietary habits. A balanced diet consisting of fruits, vegetables, whole grains, fish, and various plants will significantly help you lower your LDL cholesterol level. It’s best to limit the amount of red meat, eggs, and dairy you consume. Plant-based diets not only help lower your LDL, but they can also help clear plaque buildup from your arteries.
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New Blood Test Better Predicts Heart Attack Risk

LDL Particle Number

The Quebec Cardiovascular Study was the first large study demonstrating that heart attack can occur when a person’s LDL particle number is high and LDL level is low.8 This has been repeatedly confirmed in other studies, most recently in the AMORIS study, which enrolled a remarkable 175,000 participants and demonstrated the superiority of LDL particle number (measured as apoprotein B) in predicting heart attack risk.9 This measure can be thought of as actually counting the number of LDL particles in one cubic centimeter, or one milliliter of blood.
LDL particle number is among the most powerful tools we have to predict the risk of heart attack. It can be measured directly as LDL particle number by the nuclear magnetic resonance spectroscopy method or indirectly as apoprotein B, which is a more widely available method. Apoprotein B is the major protein particle of LDL, with a single protein per LDL particle. Apoprotein B thus provides a “count” of LDL particles.
How can LDL level be low when the particle number is high? Because the amount of cholesterol contained per particle can vary widely. If you have many LDL particles that contain less cholesterol in each particle, the conventionally measured LDL level will be low, but your heart disease risk will be high. Greater numbers of cholesterol-containing particles in the blood means more cholesterol deposition in plaque. The combination of low LDL level and high LDL particle number is very common, creating a situation whereby many people are mistakenly told that they are not at risk for heart attack.
High LDL particle number responds to the same treatments as high LDL level, but this method of assessment provides greater confidence in determining who to treat and how intensively to do so. Statin prescription drugs lower LDL particle number, as does the non-statin prescription drug ezetimibe, though it is less potent. Niacin (vitamin B3) lowers LDL particle number less potently than the statins, but will achieve a 10-20% reduction. In addition to prescription medicines, many nutritional strategies can lower LDL particle number.
High LDL particle number can be a source of danger even when LDL level has been reduced by treatments such as cholesterol-lowering statin drugs. This is why people who take a cholesterol-lowering medication can still suffer a heart attack. LDL particle number provides much more powerful feedback on the adequacy of treatment and is therefore a tool for further reduction of risk.10,11

Small LDL

LDL particles vary in size—big, medium, and small. The size difference is crucial. Small LDL particles are a far more destructive force than their larger counterparts. Like finely tuned weapons designed to wreak maximum damage, smaller particles more effectively penetrate the cellular barrier and enter arterial walls, contributing to atherosclerotic plaque. They also persist longer in the circulation, which allows more opportunity to cling like little magnets to tissues within the walls.
Once in the arterial wall, small LDL particles are more prone to oxidation, which stimulates the release of inflammatory and adhesive proteins. Small, dense LDL promotes endothelial dysfunction and enhanced production of pro-coagulants by endothelial cells. Small, dense LDL thus appears to be more atherogenic—that is, more likely to contribute to the build-up of plaque within arteries—than normal LDL.12,13
Small LDL can be an inherited predisposition that is activated by unhealthy lifestyles and weight gain. When the genetic factors are strong, it can occur in healthy people who are not overweight. It frequently causes heart disease and is found in more than half of all people who suffer heart attacks. Small LDL particles triple the likelihood of developing coronary plaque and suffering a heart attack.
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A review of fatty acid profiles and antioxidant content in grass-fed and grain-fed beef

There is considerable support among the nutritional communities for the diet-heart (lipid) hypothesis, the idea that an imbalance of dietary cholesterol and fats are the primary cause of atherosclerosis and cardiovascular disease (CVD) []. Health professionals world-wide recommend a reduction in the overall consumption of SFAs, trans-fatty acids (TAs) and cholesterol, while emphasizing the need to increase intake of n-3 polyunsaturated fats [,].
Such broad sweeping nutritional recommendations with regard to fat consumption are largely due to epidemiologic studies showing strong positive correlations between intake of SFA and the incidence of CVD, a condition believed to result from the concomitant rise in serum low-density-lipoprotein (LDL) cholesterol as SFA intake increases [
,]. For example, it is generally accepted that for every 1% increase in energy from SFA, LDL cholesterol levels reportedly increase by 1.3 to 1.7 mg/dL (0.034 to 0.044 mmol/L) [-].

Beyond changes in genetics, some producers have also altered their feeding practices whereby reducing or eliminating grain from the ruminant diet, producing a product referred to as "grass-fed" or "grass-finished".
Historically, most of the beef produced until the 1940's was from cattle finished on grass. During the 1950's, considerable research was done to improve the efficiency of beef production, giving birth to the feedlot industry where high energy grains are fed to cattle as means to decrease days on feed and improve marbling (intramuscular fat: IMF).
In addition, U.S. consumers have grown accustomed to the taste of grain-fed beef, generally preferring the flavor and overall palatability afforded by the higher energy grain ration[
]. However, changes in consumer demand, coupled with new research on the effect of feed on nutrient content, have a number of producers returning to the pastoral approach to beef production despite the inherent inefficiencies.
Research spanning three decades suggests that grass-only diets can significantly alter the fatty acid composition and improve the overall antioxidant content of beef. It is the intent of this review, to synthesize and summarize the information currently available to substantiate an enhanced nutrient claim for grass-fed beef products as well as to discuss the effects these specific nutrients have on human health.
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Does Fish Oil Raise Cholesterol?


  • Several studies have, indeed, confirmed that fish oil raises LDL cholesterol, usually by 5-10 mg/dl. Occasionally, it may be as much as 20 or more milligrams, as in Katie's case, enough for some people to be scared away from continuing this supplement. 

    Unfortunately, many physicians often assume that it's the (minor) cholesterol content of fish oil capsules, or some vague, undesirable effect of fish oil. It's nothing of the kind. And, if you were to rely on basic cholesterol values, it does indeed appear to be the case.

    But it's not.
    What has happened is that triglycerides have been reduced. Triglycerides occur in particles called very low-density lipoproteins (VLDL) and intermediate-density lipoproteins (IDL). Given Katie's high triglyceride level of 201 mg/dl before fish oil, we can safely assume that VLDL and perhaps IDL (a less common pattern) were also elevated in Katie's blood. Fish oil effectively reduces triglycerides, as it did in Katie, and VLDL and IDL are also reduced. Since LDL particles start out as VLDL particles (the first particle that emerges from the liver), fish oil can cause a "shift" of particles from VLDL to LDL. Thus, the apparent rise in LDL.

    Another factor: Conventional LDL cholesterol is a calculated value, not measured. (Many people are surprised when they first hear this.) The calculation for LDL is thrown off-sometimes considerably-by any reduction in HDL or rise in triglycerides from average values. In Katie's case, the rise in HDL from 48 to 54 mg/dl along with the reduction in triglycerides from 201 to 92 mg/dl mean that calculated LDL has become more accurate and rises towards the true measured value. The actual rise in true LDL cholesterol may be small to none.

    Omega-3 fatty acids from fish oil therefore provide the appearance of raising LDL cholesterol, but the actual-measured-rise is usually small to none.

    Omega-3 fatty acids have been convincingly shown to reduce risk of heart attackstroke, heart rhythm disorders, and are powerful tools to reduce triglycerides. It's a shame to avoid this wonderfully effective and healthy tool because of the appearance of rising cholesterol.
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Small LDL Cholesterol: Epidemic of the New Century


There's a new risk factor for heart disease-and it's not high cholesterol. It's rapidly skyrocketed into first place as the number one most common trigger for heart disease.

Ask your family physician what the number one cause for heart disease is, and he/she will likely reply "high cholesterol" without hesitating. Most Americans would answer the same. After all, the media overflows with discussions about cholesterol and how drugs can reduce it.

Just 30 years ago, small LDL was far less common because lifestyles were different and the technology for identifying small LDL was unavailable. Why the surge in the small LDL pattern? Two reasons: 1) The explosion of excess weight and obesity in the U.S., which triggers formation of small LDL particles, and 2)over-reliance on processed carbohydrates, especially wheat-based convenience foods, that increase expression of the small LDL pattern enormously. 

Small LDL has climbed into first place as the number one cause of heart disease. (Number two: low HDL cholesterol.) Given current trends, as many as 80-90% of those with heart disease, 40-50% of the overall adult population may harbor this pattern.

Official agencies like the American Heart Association and the USDA have lost touch with the emergence of small LDL as a trigger for heart disease. The USDA Food Pyramid, for instance, advises American adults to eat 6-8 servings of grains per day. This advice is a sure-fire method to ignite expression of the small LDL pattern. The American Heart Association's Heart Check Mark program endorses products like Cocoa Puffs, Berry Kix and Cookie Crisp cereals and hundreds of other similar products as "heart healthy" that likewise act as potent triggers of the small LDL pattern.
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Why “Average” Cholesterol Values Can Be So Bad


Jack had been told again and again that there was absolutely nothing wrong with his cholesterol panel.  Jack’s doctor declared that there were no abnormal values and LDL cholesterol was below average. Jack received a pat on the back and reassurance that his heart was in good shape. So his primary care physician was totally stumped when Jack was diagnosed with coronary heart disease.
With all the fuss about cholesterol, how can such a thing happen? Does it mean that cholesterol, LDL in particular, should be even lower to provide protection against heart attack and heart disease? Not necessarily. What it does mean is that the causes for heart disease should be sought beyond cholesterol.

With all the fuss about cholesterol, how can such a thing happen? Does it mean that cholesterol, LDL in particular, should be even lower to provide protection against heart attack and heart disease? Not necessarily. What it does mean is that the causes for heart disease should be sought beyond cholesterol.

With Jack, we performed a blood test called lipoprotein analysis using a technique called nuclear magnetic resonance, or NMR. Despite the seemingly complicated name, it is a simple blood test that, in my experience, uncovers hidden causes for heart disease even when standard cholesterol numbers look fine. Jack's lipoprotein panel told an entirely different story.

In this technique, there is an actual count of the number of LDL particles present in Jack's blood, rather than the calculation usually used to obtain standard LDL cholesterol. Jack's LDL particle number was 1880 nmol/l, a very high value among the worst 10% of men and women. LDL particle number of 1880 nmol/l is approximately the same as LDL cholesterol of 188 mg/dl (simply drop the last digit to generate an approximate "true" LDL), almost 70 mg higher than the estimated value of 119 mg. (This degree of inaccuracy, in fact, is not at all uncommon.)

Lipoprotein analysis also examines the size of LDL particles-large, small, or in-between. 95% of all Jack's LDL particles were small, a very severe pattern. The Quebec Cardiovascular Study is among the clinical studies demonstrating that the combination of high LDL particle number and small LDL raises heart disease risk by 600%.

Jack also showed a severe excess of intermediate-density lipoprotein (218 nmol/l). This is an important pattern that suggests that dietary fats are not cleared for 24 hours or so after a meal, a phenomenon that heightens risk for carotid disease and strokeaneurysms, as well as heart disease.
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