WLS and High Cholesterol

Interesting report form the ASMBS:

https://newswise.com/articles/surgery-to-treat-high-choleste rol

Personally, at 12 years out, I am still maintaining my post-op normal cholesterol levels, although a recent blood test revealed that my triglycerides are back above normal level (although not as high as it was pre op). Need to check with my PCP on that strange thing at next check up.

Even at my highest weight of 481 lbs, my cholesterol was 152. My triglycerides were at 150. Post op, I don't even know what my cholesterol was. They didn't bother checking. My triglycerides dipped to 100. I know it all could change, but I am not worried for now.

Cholesterol is probably one of the most misunderstood lab values, and they don't necessarily indicate health or risk. My cholesterol was 93 (literally just 93) after my VSG in 2015, and more recently after the revision it was 130ish. Low cholesterol is actually bad if it's too low like that, as it can correlate with mood dysregulation (depression) among other stuff. Many cells require cholesterol for their structures and integrity, though, as well as the majority of brain cells... we actually are held together by it :)

My friend Dave Feldman has one of the best science websites about it on the internet period. You might find it interesting though they don't talk about bariatrics.

Generally, high cholesterol isn't as problematic as you may think. Fasting and feasting can also drastically change the lab values...you can artificially force it to be lower for instance. What matters more for cardiovascular health is what's called cardiac calcium scoring. This is a far more certain and definitive indication of CVD risk, and it's a test you technically need only ~10y.

I agree with a lot of what you've said. Cholesterol readings are biomarkers, not a disease state in and of themselves. And treating people with a cholesterol of like 230 with statins maybe more harmful than helpful.

That being said, I think it's interesting to note that in the Framingham Study (multi generational cohort study out of Framingham, MA by the National Heart, Lung and Blood Institute in conjunction with Boston University) have noted almost extremely few cardiac events in people with overall cholesterol of under 150. The study has tracked over 5,000 adults - now over 3 generations. Interesting stuff.

Prior to Ancel Keyes, cholesterol of over 200 was not considered unhealthy. Keyes' research was subsidized heavy by industry that benefited from promoting low-fat diets. With their backing he advocated for medical standards we still use today. Medical standards are, unfortunately, frequently beholden by bias and marketing just as much as science, sadly.

Framingham, which I am very familiar with, is unfortunately also exceptionally correlational. Cardiac events are not necessarily predicted the best by cholesterol in general. Calcium scoring is more reliable because it's a stable measurement as it not affected in the short-term by hormones or diet; very few medical tests can offer the same ten year guarantee, for instance.

The problem is that cholesterol is exceptionally dynamic and changes depending on far too many factors. Time of day, dietary intake, and so on. Cholesterol is a measure of how much of a particular substrate your body is currently transporting. Excluding egregious outliers, all it tells us is your body is, for whatever reason, transporting lipids. It doesn't say why, necessarily, or for what purpose. That's where the devil in the details is.

Also, regarding CVD, the reason people have, say, a heart attack is a blockage that prevents blood from getting to cardiac muscle. The fat is not the issue - the arteriosclerosis is. This is caused by high serum insulin as well as long-term inflammation. Fat, and cholesterol, aren't really the cause.

If a road has a giant pot hole caused by frequent icy roads and you hit it and bend your rims, it's not the fault of the ice...not really. It's not even necessarily caused by the pot hole, though the rim was bent driving over it. The real cause is the delay of the city in fixing it.

The fat is just a car on the road; it's the roads that are damaged and cause CVD...not the cholesterol.

Probably the best way to reduce CVD is independent of cholesterol...by keeping serum insulin as low as possible and avoiding foods which spike it. Avoiding all inflammation-causing substances in general, such as smoking, alcohol, stress, and so forth. That has far more of an effect on CVD's development, IMO, because there are a significant amount of people who experience heart attacks with low cholesterol, too. Inflammation tends to be a far more common correlate, and causation, in a lot of contemporary research.

Agree that the study is correlational in nature for sure. It's so tough to get a good double blind PCT on issues that develop over the course of a lifetime (or some long subset thereof, or muti-generational in the case of the Framingham). That's why so many of these studies tend to be epidemiological in nature. And why a preponderance of evidence, and meta-analysis of data (which has it's own pitfalls) is so common to see the long term impact. However, they are all correlational by definition when you are looking at large studies over very long periods of time.

Anyway, all interesting stuff. And yeah, didn't the cutoff for high cholesterol used to be like 300 or 330 or something?

It was something that would make most PCPs flip out these days, that's for sure, ha. Personally I think statins are more dangerous than the cholesterol itself, too. That's also a tangent...

Check out Dave's work, though, if you are interested. It's exceptionally impressive given he is not a formally-trained scientist. I'm rarely impressed, and I was very much so when I first read it.

Yeah, no kidding! The doctor would FLIP.

I think we are probably aligned on that whole statin thing. I could have a whole tangent not only on statins, but the whole approach of treating bio-markers (and claiming success on the change in those bio-markers) as opposed to treating the root causes (and measuring success on the elimination of actual health concerns like heart attack, stroke and all-cause mortality), but yeah.....another day.....;-)

I'll check out that website when I have some time - looks like there is a lot there. I love this stuff. And I do try and read all viewpoints, not just my own. I'm sure I suffer from confirmation bias as much as the next guy, but I try....

If you don't mind me asking, what kind of revision did you have? I had the sleeve approx 12 years ago, but due to chronic gerd and a hernia my surgeon is recommending that I have a revision to rny bypass. If this is what you've had done can you tell me if your experience with the revision. Why did you need a revision.

Also, I have kept my weight off for approx 12 years until a fall in February. I had multiple steroid injections and also thyroid problems. I have put on approximately 30-35 lbs. When you had the revision did it help you lose more weight?

Thanks,

PParker