Record-breaking temperatures stretched across the United States this summer. Severe storms and catastrophic floods are causing mass devastation around the world. Signs of the changing climate have become impossible to ignore.
Teenagers are taking it all in.
Amid the general mental health crisis among youth, the specific issue of climate anxiety is surging. A nationally representative EdWeek Research Center survey found that 37 percent of teenagers feel anxious when they think about climate change and its effects, and more than a third feel afraid. Many also said they feel helpless and overwhelmed.
“I feel like generally there’s a lot of hopelessness among people my age,” said Croix Hill, a 16-year-old junior at Benjamin Franklin High School in New Orleans. “When talking about it, people are just kind of like, ‘Well, whatever. We’re not even gonna have a planet in 50 years, so it doesn’t even matter.’”
The consequences of climate-related distress are profound for youth. The fear of climate change is influencing their decisions about where to attend college, whether to stay in their hometowns as adults, and even whether to have children. In some cases, these feelings can adversely affect young people’s ability to function on a daily basis, experts say.
What is ‘climate anxiety’?
The term climate anxiety encompasses all the difficult emotions—anxiety, fear, sadness, grief, anger, helplessness, powerlessness, and guilt—that people can experience when confronting the climate crisis, said Britt Wray, a human and planetary health postdoctoral fellow at Stanford University and the London School of Hygiene and Tropical Medicine who has written a book, Generation Dread: Finding Purpose in the Climate Crisis.
While climate anxiety is present in people of all ages, Wray said, it’s most prevalent among young adults. She’s seen climate anxiety in high schoolers, middle schoolers, and even children as young as 8.
Yet experts warn that school counselors or teachers aren’t prepared to help students emotionally grapple with the climate crisis—something that both social-emotional and climate advocates are hoping to change. Climate change education is spotty and limited across the country, and many teachers don’t receive training or support to teach the science fully and accurately—to say nothing of its social-emotional toll.
“This is an existential human crisis that I think teachers are not prepared to address,” said Chelsey Goddard, a vice president at the Education Development Center who leads the global nonprofit’s health, mental health, and behavioral health work in the United States. “Just to address climate change in the context of science [isn’t] addressing the social-emotional and social science aspect of this crisis.”
I feel like generally there’s a lot of hopelessness among people my age.
Climate anxiety isn’t a clinical mental disorder; rather, the growing consensus in the field is that it’s a natural response to a real and existential threat, Wray said.
The vast majority of scientists agree that climate change is driven by human activity and, if left unchecked, will lead to disastrous consequences, such as extreme heat and more severe storms that displace millions from their homes.
“[The anxiety] can be really hard to deal with because of the intensity of the climate crisis, and the fact that solutions for this crisis aren’t reconcilable by any individual,” Wray said. “There can be a bit of a trapping in the anxiety that occurs when a person feels like they aren’t in control and aren’t able to address the threat by finding the right solution for it.”
Teenagers say they feel anxious, afraid, and helpless
The EdWeek survey, conducted in October, presented teenagers a list of 11 emotions—ranging from angry to optimistic to uninterested—and asked them to select all that apply when they think about climate change and its effects. The top response? “Anxious,” followed closely by “afraid” and “helpless.”
Just 17 percent of the teenagers, who ranged in age from 14 to 18, said they felt optimistic. Only 8 percent said they were unconcerned.
Croix has lived in New Orleans since she was 2. The city is home, but the signs of climate change are everywhere—from remnants of debris from Hurricane Ida, which ravaged the city in 2021, to the wafting smell of controlled marsh fires, which are regularly set to boost the health of wetlands and reduce the sea level rise that’s contributing to the disappearance of Louisiana’s coastline.
She’s also painfully aware of the oft-cited threat that New Orleans could be underwater in the coming decades as sea levels rise. As Croix considers where to apply to colleges, she increasingly feels like New Orleans won’t be where she ends up.
“The increase in hurricanes and detrimental tropical storms that we’ve been experiencing definitely influences the decision that I’m making as far as college and my plans, because I don’t know if that’s something I want to have to deal with,” she said. “I love New Orleans, it’s my city, but I just don’t know if … evacuating every single year, and it getting worse and worse, is something I can deal with.”
Croix isn’t alone in that calculus: A fifth of teenagers said the threat of climate change has impacted the location of where they’d prefer to attend college, and 37 percent said it’s affected where they want to live as an adult, according to the EdWeek survey.
“I feel like the more south you go, the hotter it gets,” said Ocean Bardwell-Jones, a 17-year-old senior at Waiakea High School in Hilo, Hawaii. “Given that I want to be a lawyer, I would not want to wear a suit all the time in a hot environment. That would be awful.”
Ocean and his classmate Alexander Tuson feel like they’re in a bubble in their corner of Hawaii, with its lush rainforests and waterfalls. But the threat of climate change still scares them.
“It feels kind of safe here, but we read all the articles about the giant floods in Pakistan—it’s intimidating,” said Alexander, who’s 18. And he’s noticed signs of environmental distress around him.
“There’s no coral anymore,” Alexander said. “There are some beaches close to here, and there used to be a lot of coral there, and it’s kind of a dull color right now. … I’ve never seen really bright-colored coral, and I think there used to be.” (Coral loses its color as a result of pollutants in the water or rising sea temperatures.)
Meanwhile, a quarter of teenagers said the threat of climate change has affected whether they want to have children, the EdWeek survey found.
“I don’t know anybody my age who’s like, ‘Yeah, I want to have kids,’” said Jia Sharma-Chaube, a 15-year-old junior, also at Benjamin Franklin in New Orleans. “I think the idea that it’s just a natural course—you’re going to get to grow up and get married and have a good job and get a house and have kids—that’s becoming less and less of a realistic option for people my age.”
She added: “I love kids, but like—I don’t know, I just wouldn’t feel comfortable with that, I guess.”
“When I talk to young people, … even though they’re not at all in a place to be thinking about who they might have kids with and all the rest of it, they’re so stressed out about their future that they don’t think it’s fair or responsible to imagine putting another person in that situation as it gets worse,” Wray said.
Educators can help students manage their climate anxiety
Students who are wrestling with climate anxiety need to feel heard and understood, experts say. It can help to have “people with whom you can dwell on these emotions and explore them without fear of someone minimizing them or brushing the distress off as catastrophic thinking,” Wray said.
But often, teenagers say they don’t receive that type of validation from adults in their lives.
“My friends are like, ‘Oh, I talked to my mom, and I’m like, ‘The planet is going to be dead by 2050,’ and she’s like, ‘That’s what they’ve been saying since I was a kid, and it hasn’t died yet!’” Jia said. “It feels kind of like, dismissive.”
I don’t know anybody my age who’s like, ‘Yeah, I want to have kids.’
There’s a growing movement for mental health professionals to be trained to treat climate anxiety. And some universities are in the initial stages of starting to offer climate stress therapy for students, the Washington Post has reported.
But so far, this conversation has been largely missing from K-12 schools, where there are already not enough school counselors to meet young people’s growing mental health needs, experts say.
While the National Association of School Psychologists adopted a resolution in April 2021 to support efforts to reduce the harmful effects of climate change on children, tackling climate anxiety hasn’t been at the forefront of the group’s priorities, said Kelly Vaillancourt Strobach, the director of policy and advocacy for the group.
“This is an issue that students are paying attention to, … [but] I wouldn’t say that it’s necessarily rising to the top of things we hear,” she said, citing other mental health challenges for young people that have been exacerbated since the pandemic.
Plus, targeted interventions for climate anxiety, especially in high school or middle school students, are still in a nascent phase of study, said Lian Zeitz, the co-founder and director of programs for the Climate Mental Health Network, a nonprofit funded by the Global Fund for Mental Health.
“What does it mean for a generation of young people to be experiencing such existential dread?” he said. “How do we build tools and resources that promote resilience and climate-related action and social connection—things that serve as antidotes to the negative effects of that existential dread, which can be despair and apathy and inaction and maybe isolation, [which can] become depression.”
The Climate Mental Health Network is working with partners to develop resources for middle school teachers to incorporate social-emotional learning practices into science lessons and discussions on climate change. It plans to pilot these resources next school year.
Teachers will need support and self-care while having these conversations, Zeitz added: “It isn’t easy navigating existential conversations with young people or kids that are saying they don’t want to have babies because the climate is ending and everything’s on fire.”
Climate anxiety can be incorporated into districts’ SEL work, experts say
Despite schools’ emphasis on social-emotional competencies and wellbeing, climate anxiety generally hasn’t been a part of that work, said Shai Fuxman, a senior research scientist at the Education Development Center, which works with districts across the country on their SEL needs.
“The connection between that and climate change and climate anxiety hasn’t been made, but it’s not a difficult link to make,” he said. “The skills that we’re already teaching—around self-empowerment, managing emotions, developing goals and setting goals and achieving goals—those are all skills that can easily be applied to the conversations that teachers are having with students around climate change.”
Experts say that teachers should foster a sense of agency and self-efficacy among students when they discuss climate change. While climate change is largely driven by corporations, individuals can still take action—and more than half of the teenagers who responded to the EdWeek survey said they wanted to learn in school what they could personally do to lessen the effects of climate change. About a quarter said when they think of climate change, they feel motivated.
Fuxman said the climate crisis is an opportunity for educators to teach about collective action and working with others toward a common goal.
“Not only will it help address climate change, but it’s a good skill for them to have anyway—to feel a part of something bigger can actually help build self-esteem,” he said. “Like, ‘I’m part of the movement and part of something that is happening to save our planet.’ I think it can be restoring, too, from a mental health perspective.”
While teenage activism around climate change often makes headlines, few survey respondents said they’ve attended climate demonstrations or contacted elected officials in the past two years. Thirty-seven percent of teenagers say they haven’t taken any actions related to climate change during that time period.
“I think a lot of kids are frozen—they either want to push it out of their minds and not think about it, or they’re frozen,” said Goddard, of the EDC. “People will say, ‘Oh, kids just don’t care,’ or, ‘Look at these really wonderful kids out there being activists,’ but there’s this whole group in the middle that I think often just feels like they’re stuck.”
The facts of climate change are overwhelming, but Goddard said it can help for teenagers to work toward change in their own community, such as petitioning school officials to install solar panels on buildings.
“You can’t say, ‘I’m gonna change the world.’ You have to break off a piece of it,” she said.
Schools may have to navigate politically tricky waters
One potential barrier to schools’ helping with the social-emotional toll of the climate crisis? Politics.
“We’re really thinking about how we get resources to people in a range of contexts,” said Zeitz, of the Climate Mental Health Network. “I don’t have all the answers about how to do that, but it’s been clear for us—if we’re really trying to reach more young people and more school systems, we’ll just have to be adaptive to how certain things are framed based on education legislation.”
This work also may require a mindset shift among the adults in school buildings, said Wray, the author of Generation Dread. For one thing, adults will have to come to terms with the fact that young people have a different mindset than they did about their futures.
“Have compassion for that and get curious about really trying to understand the granularity of what that climate anxiety feels like—how it can make a young person feel futureless and abandoned by older generations, which is profound psychological distress that can tear away at the social underpinnings of wellbeing,” Wray said.
After all, climate anxiety can lead to teenagers feeling unmotivated, distracted, and in particularly severe cases, depressed or even suicidal, Wray said: “It’s a serious issue that demands serious consideration and support.”
The NPC Armed Forces Nationals is a contest that recognizes and supports members of the United States military and their families. Many of the athletes that compete on that stage every year are simply looking to improve themselves and perhaps explore a new athletic endeavor. They also want to feel like they belong in a community. That’s why they train and diet so hard to face the judges on that stage.
One of those judges is Luis Santa, a man who is familiar with both commitments the athletes make – as competitors and servicemembers. That’s because Santa is not only a retired IFBB Pro League competitor, he’s also an active member of the United States Air Force. Santa works in the Pentagon in Washington, D.C. His job is to analyze data and artificial intelligence.
“In a sense, I’m your bodybuilding nerd,” Santa joked. Both his passion for service and bodybuilding originated in Puerto Rico, where Santa spent part of his childhood as well as the early years of his adult life. After working at a fast-food restaurant and being robbed at gunpoint, Santa felt he needed to be a part of the solution. So, he joined the local police force.
“By joining the police department, I went into a tactical unit. Almost every single cop in that unit was a member of the Army National Guard,” said Santa. “When we were being trained with new weapons, these guys knew how to use them already, and I had never seen any of these weapons.”
Courtesy of Luis Santa
After finding out that his fellow officers were also in the military, and because at the time he was working multiple job to make ends’ meet, Santa decided that he had to join as well. After going to a recruiter’s office with his team members, he decided to join the United States Air Force. After taking the ASVAB test, the recruiter told him that he could qualify for any job he wanted.
“I told him that I was a car mechanic, and I could work on motorcycles as well. I think it’s pretty interesting to work on aircrafts. He said ‘oh, man, I have a guaranteed job. You will go to basic training, and you’ll go straight to tech school for that job, which is tactical aircraft mechanic.’”
Courtesy of Luis Santa
On December 6, 2001, Santa accepted the opportunity, and that decision started a career that he is still involved with over two decades later. After initially wanting to serve as a way to improve his career as a cop, Santa would transition to working in the military full-time. That career would include three deployments. One of those was to serve during Operation Iraqi Freedom, and he considered that the most significant moment of his military career thus far.
“It was a pretty shocking thing that I felt I was going to do, and I also felt like my call for duty was in full effect.”
Another call that he was pursuing at the time was bodybuilding. That side of Santa’s life can be traced back to his childhood as well. His father made sure he played as many sports as possible to stay active. Sports were a part of his childhood through his time in Puerto Rico as well as New York and Connecticutt. Once he grew up, he kept up a regimen of doing pushups and situps every day, which helped him maintain a good physique. His shape caught the eye of a local bodybuilder, who convinced young Luis to compete in a show. His first show was in 1997, and he recalled the experience as if he just walked offstage.
“The good news was that I finished second in my show. The bad news was there were only two guys in my show.”
Nonetheless, Santa was bit by the bodybuilding bug, and he decided to compete again. He would win the welterweight novice class of the Mr. Puerto Rico in 1998, which featured 24 competitors. Fast forward over a decade later, and Santa had earned his IFBB Pro League card by winning the 2011 NPC USA’s Middleweight title. He had actually won his class in years’ past, but due to the few pro cards that were issued at the time, he didn’t get to move up. Once he did attain pro status, he made up for lost time by competing in a show right before a deployment.
“I was already 37 years old, so I needed to get on a pro stage asap. So, I jumped right into the New York Pro. One reason I did that was because I had to go back to the Middle East, and I wanted to make sure I had a show in because I didn’t know if I was coming back.”
Fortunately, Santa did come back and competed several more times. He would eventually win a show, the 2017 Baltimore Classic Masters Pro. He also placed seventh at the Tampa Pro 212 that year. Derek Lunsford would win that contest. Santa called that his most successful season as a pro, but he was actually prouder of his showing in Tampa, even though he won in Maryland.
“I was very happy with what we managed to do with my physique,” he stated. The “we” referred to himself as well as his coach at the time, A.J. Sims, who worked with Santa for the rest of his career. What makes Santa most proud of his career is that like fellow pros Charjo Grant and Olympia 202 champion David Henry, he successfully prepped for contests while maintaining his commitments to his country.
“To prepare while doing shifts in the military and have a family, it’s tough to get it done. I always felt the most rewarded on the day of the show that I made it to the show.”
Santa’s career onstage would conclude in the 2021 Toronto Pro, where he placed sixth in the 212 division. Even though he doesn’t compete anymore, he still trains hard and is still connected to the sport, both as a judge and promoter. In his eyes, it’s a way to give back to the community and sport that has been a strong part of his life.
“I am passionate about the sport just like I’m passionate for my (military) career.”
Besides serving his country in the Pentagon, Master Sergeant (E7) Santa still sees himself as an advocate for both fitness and service. He re-upped this year to add three more years of service, and he’s open about encouraging young people to consider a future in the United States Armed Forces because it would mean something far greater than a paycheck alone.
“It’s a different feeling. I really can’t explain the feeling of the love for some people to serve. It’s a very special feeling of accomplishment and gratification. I feel that on the inside. It’s a very strong feeling of satisfaction to be able to serve.”
AMA Update covers a range of health care topics affecting the lives of physicians, residents, medical students and patients. From private practice and health system leaders to scientists and public health officials, hear from the experts in medicine on COVID-19, monkeypox, medical education, advocacy issues, burnout, vaccines and more.
Featured topic and speakers
Featured topic and speakers
In today’s AMA Update, it’s National Influenza Vaccination Week and AMA Vice President of Science, Medicine and Public Health Andrea Garcia, JD, MPH, reminds you to #FightFlu by getting your flu shot.
Also covering the latest news on coronavirus from a post-Thanksgiving surge, what doctors need to know about monoclonal antibody treatments and Pfizer BioNTech submitted an Emergency Use Authorization application to the FDA for its omicron-targeting coronavirus booster for children younger than 5. AMA Chief Experience Officer Todd Unger hosts.
Andrea Garcia, JD, MPH, vice president, science, medicine & public health, American Medical Association
Transcript
Transcript
Unger: Hello and welcome to the AMA Update video and podcast. Today we have our weekly look at the headlines about the tripledemic with the AMA’S Vice President of Science, Medicine and Public Health, Andrea Garcia in Chicago.
Unger: Well, we’re going to talk about COVID, we’re going to talk about flu and we’re going to talk about RSV. Lots to cover this morning. Why don’t we start with COVID. I’ve seen a lot of info on the new crop of Omicron some variants that have been driving case counts in the last few weeks.
What’s the situation there?
Garcia: So last week we talked about how those new Omicron subvariants BQ.1 and BQ.1.1 were just starting to account for over 50% of COVID cases here in the U.S. And if we look at the CDC numbers out this week, those two variants combined now account for about 63% of new cases. So they’re continuing to spread. Those numbers are trending upward and we’re seeing them represent a growing proportion of cases.
The proportion of cases attributed to BA.5 continues to decrease. That number is now at about 13% of new cases. And last week we also talked briefly about the XBB subvariant. That doesn’t appear to be much of a threat yet.
It currently accounts for only about 5% of new cases. And we just saw about a 1% increase from last week. So really that’s a pretty small percentage of our cases here in the U.S. right now.
Unger: Well, we’re coming out of Thanksgiving in November and heading into the holidays hoping we can avoid a surge. Is that likely or not?
Garcia: So avoiding that surge is starting to look more and more unlikely. If we take a look at the New York Times data, the average number of new COVID cases is around 52,000. Unfortunately, that’s a jump of about 28% over the last two weeks. So it’s a pretty sharp increase for that time period.
The New York Times is reporting that that relative stability that we had been talking about over a number of weeks, that could be coming to an end.
Unger: That is a sharp increase. And that’s not good news. How is that affecting things on the hospitalization and death front?
Garcia: So unfortunately, the average number of hospitalizations due to COVID has also increased sharply. That number’s at the highest point it’s been in over the last three months. And what we’re seeing is that post-Thanksgiving increase, the number of hospitalizations is around 36,000.
Also, a 28% increase over the past two weeks. A few states reported per capita increase—all but a few states reported that increase over the past week. And the number of patients in ICUs due to COVID is also up. And that’s up about 22% over the past two weeks as well.
Unger: It’s kind of interesting that at this point despite the kind of increases in cases that we’re seeing in hospitalizations, it doesn’t look like it’s yet translating into an increase in COVID deaths. What’s the story there?
Garcia: Yeah, so that average number of daily deaths has fallen slowly but steadily since September. And that trend seems to be continuing. For now, we’re at about 250 deaths due to COVID reported each day. It’s actually a 12% decrease over the last two weeks.
That does seem to run counter to the number of cases and hospitalizations. But I think it’s important to remember that deaths are a lagging indicator. So we’re just starting to see those increases of cases and hospitalizations.
So it’s not too surprising at this point to see that number of deaths decreasing at this point in time.
Unger: And one interesting development is that the majority of people who are dying of COVID are now 65 years and older. What is going on there?
Garcia: Yeah, so the Washington Post actually recently called COVID a plague of the elderly. And that same article noted that nearly 9 out of 10 deaths are now in people 65 and older. And that’s the highest rate since the pandemic began.
While COVID deaths are falling, people are still dying of COVID. And that’s, if we look at the rate, it’s about two to three times the rate at which people die of flu. While most of the country is trying to return to some semblance of normalcy, the CDC director did acknowledge that deaths among the elderly, especially those with multiple chronic conditions, is a real challenge. And to minimize further loss of life, the White House did announce last week that it is launching a 6-week push to increase booster uptake in seniors and other groups that we know have been disproportionately affected by COVID.
Unger: And it sounds like we need a push for that because the booster numbers still really lagging. What are the specific figures there?
Garcia: So since we talked last week, we’ve seen about five million more people receive that new bivalent booster shot. But according to CDC, that totals almost 40 million people in the U.S. It sounds like a big number but it only represents about 13% of the U.S. population who is eligible for that booster dose. And just a reminder, that updated booster is available for those five years and older.
Unger: And how about the timeline for children who are younger than that?
Garcia: So we’ve seen some movement there. We know that on Monday, Pfizer and BioNTech submitted an EUA application to the FDA for that bivalent COVID vaccine for children younger than five. The company reported that the bivalent vaccine would be the third dose in a primary series for children six months through four years of age.
So if authorized, children in this age group would receive a primary series that can consist of two, three microgram doses of the original Pfizer BioNTech COVID vaccine, followed by a third three microgram dose of the Omicron BA.4/BA.5 bivalent vaccine. And the thinking here really is that given the high level of respiratory illnesses circulating among children under five that these updated COVID vaccines may help prevent severe illness and hospitalization.
Unger: Well, we’ll continue to watch how that plays out. Also news about monoclonal antibodies seem to have lost a little arrow from the quiver there. What do physicians need to know about that?
Garcia: So physicians need to know that the FDA rescinded the EUA for Bamlanivimab last week. It was the last monoclonal antibody treatment still authorized in the U.S. for COVID. The FDA, over the course of the pandemic, authorized six different monoclonal antibody treatments. And with Bamlanivimab the rise of Omicron and its subvariants, those treatments have been rendered less effective.
So the FDA has gradually revoked each one of those authorizations. According to the FDA, the drug was not expected to neutralize the Omicron subvariants BQ.1 and BQ.1.1, which as we just talked about accounts for the majority of new cases here in the U.S. There are other treatments still available, so health professionals should use Paxlovid, which we know is still effective. And for patients with immunosuppressive disease or other immunosuppressive conditions, convalescent plasma is still authorized for COVID-19 treatment.
Unger: Well, let’s move on and talk a little bit more about the flu, which is driving a big surge at hospitals across the country right now. Start with just the basic figures about how we’re doing this week?
Garcia: Yeah, so if you look at the CDC FluView data, seasonal flu activity is high and it is continuing to increase across the country. The estimates are that flu has caused at least 8.7 million illnesses, 78,000 hospitalizations and 4,500 deaths. I think it’s important to remember that it is National Influenza Vaccination Week. It is a great time to remind patients to get their flu shot.
AMA Board Chair Dr. Sandra Fryhofer participated in a media briefing with Dr. Walensky this week and said I can tell you firsthand, this year’s flu season is off to a rough start. She reminded people that we’re no longer in that protective bubble we were in during COVID. And with RSV and COVID also circulating, it’s more important to get that shot as soon as possible.
Unger: Andrea, I know that the flu shot is a little bit of a guessing game most seasons. What is it looking like in terms of effectiveness for this year?
Garcia: Well, both Dr. Fryhofer and Dr. Walensky noted during the briefing that this year’s flu vaccine formulation seems to be a good match for the viruses that are circulating. The flu vaccines this year are quadrivalent. They cover four strains—two Flu A’s, H1 and H3, and two flu B lineage viruses. And so far, most of the cases we’re seeing are influenza A. That could certainly change.
So different flu strains can circulate within the same flu season. That means you can get flu more than once. And it also means even if you’ve had the flu already this season, you should still get vaccinated. Dr. Fryhofer noted during that media briefing that it does take two weeks to build up those protective antibodies. So get the vaccine now.
And you can also get your flu shot and your COVID booster at the same time. Everyone six months and older is eligible for the flu shot. CDC is also providing resources for physicians to make getting this message out easier. And we will include the link in the description of this episode to those resources.
Unger: Very important getting that flu shot. Last leg of the tripledemic is RSV. It’s been circulating, obviously, in higher than usual amounts as well. How are we doing on that front?
Garcia: So as we’ve talked about over the past few weeks, pediatric hospitals have been more full than usual in recent months. And if we look at the CDC data, RSV hospitalizations are 10 times higher than usual for this point in the season. Because of reporting delays due to the holiday, we don’t have a full complete picture. But the CDC data is showing that the test positivity rate seems to be decreasing for RSV.
So it could be a sign that cases are starting to slow down. But we’ll probably have a more definitive answer about that next week as the data continues to come in.
Unger: All right, well, we’ll look forward to that. It does sound helpful but we’ll pay attention next week. That wraps up today’s episode. Andrea, thanks for being here today. We’ll be back soon with another AMA Update. You can find all our videos and podcasts in the meantime at ama-assn.org/podcasts. Thanks for joining us today and please take care.
Disclaimer: The viewpoints expressed in this video are those of the participants and/or do not necessarily reflect the views and policies of the AMA.
The protein apolipoprotein E (APOE) plays a key role throughout the body. It helps to transport cholesterol and other fatty molecules, or lipids. The gene that produces APOE comes in a few different varieties. The most common is called APOE3.
The most notorious is APOE4, which has long been linked to an increased risk of dementia in Alzheimer’s disease. People who inherit one copy of the APOE4 gene have up to a fourfold greater risk of developing Alzheimer’s dementia. Inheriting two copies of APOE4 elevates the risk up to 12-fold. But despite years of study, scientists have little understanding of how APOE4 affects the human brain and boosts dementia risk.
Earlier research by Dr. Li-Huei Tsai of the Massachusetts Institute of Technology and others found that APOE4 might raise Alzheimer’s risk by altering lipid metabolism in certain brain cells. But the underlying details of the process remained unclear.
To build on these findings, the team conducted a multipronged study that assessed gene activity of all major cell types in postmortem human brain tissue from 32 men and women who had one, two, or no copies of the APOE4 gene. Results were published in Nature on Nov. 16, 2022.
The researchers found that APOE4 affected gene expression across all measured cell types. The team then took a closer look at genes related to cholesterol and other lipids. Cholesterol-manufacturing genes were overly expressed, and cholesterol-transporting genes dysregulated, in brain cells called oligodendrocytes with the APOE4 gene. Oligodendrocytes are found in the brain and spinal cord. They make and maintain a fatty substance called myelin that surrounds and insulates long nerve fibers. The abnormalities were more extreme in oligodendrocytes with two copies of APOE4 rather than one.
To better understand how APOE4 affects oligodendrocytes, the scientists created laboratory cultures of the cells with and without the APOE4 gene. Oligodendrocytes with APOE4 tended to accumulate abnormal amounts of cholesterol within their cells, rather than using it to make healthy myelin sheaths around nerve fibers. When the scientists examined postmortem human brains, they noted that myelin sheaths tended to be fewer and thinner in brains that carried the APOE4 gene.
The scientists next used model systems to test whether APOE4-related abnormalities might be reversed via drugs that affect cholesterol processing. They found that a drug called cyclodextrin, which promotes cholesterol transport, reduced cholesterol buildup and improved myelin sheath formation in cultured oligodendrocytes. It did the same in mice with two copies of APOE4. The mice also performed slightly better in learning and memory tasks after treatment with the drug.
These findings open new avenues for exploring the underlying mechanisms of Alzheimer’s dementia and for designing potential therapeutics.
“It’s encouraging that we’ve seen a way to rescue oligodendrocyte function and myelination in lab and mouse models,” Tsai says. “I feel that lipid dysregulation could be very fundamental biology underlying a lot of the pathology we observe.”
— by Vicki Contie
This research was supported in part by NIA grants RF1-AG062377, RF1-AG054012-01, RF1-AG0540124, and R01-AG058002.
Adopting and maintaining a healthy lifestyle may prevent inflammatory bowel disease (IBD), according to findings from an analysis of three prospective U.S. cohort studies, which were validated in three external European cohorts.
In the primary analysis, maintaining low modifiable risk scores — based on risk factors including body mass index, smoking status, use of non-steroidal anti-inflammatory drugs, physical activity, and daily consumption of fruit, vegetables, fiber, polyunsaturated fatty acids, and red meat — could have prevented 42.9% of Crohn’s disease cases and 44.4% of ulcerative colitis cases, reported Hamed Khalili, MD, MPH, of Massachusetts General Hospital in Boston, and colleagues.
Moreover, adherence to a healthy lifestyle could have prevented 61.1% of Crohn’s disease cases and 42.2% of ulcerative colitis cases, they noted in Gut.
“We were surprised by the proportion of cases that could have been prevented through lifestyle modifications,” Khalili told MedPage Today. “One reason for this finding may be that our population was older and therefore most of our cases of IBD happened in older adults.”
“We know that lifestyle and environmental factors play a bigger role in the development of IBD in this population as compared to those who are diagnosed with disease earlier in life,” he added.
These findings from the Nurses’ Health Study (NHS), the NHS II, and the Health Professionals Follow-Up Study (HPFS) were largely validated in three external European cohorts — the Swedish Mammography Cohort, Cohort of Swedish Men, and the European Prospective Investigation into Cancer and Nutrition.
Looking at cases of Crohn’s disease among the European validation cohorts, adhering to low-risk factors could have prevented 44% to 51% of cases, while adhering to a healthy lifestyle could have prevented 49% to 60% cases. For ulcerative colitis, adherence to low-risk factors could have prevented 21% to 28% of cases, while healthy lifestyle adherence could have prevented 47% to 56% of cases.
For every 1-point increase in modifiable risk score, a higher risk of Crohn’s disease (P for trend<0.0001) and ulcerative colitis (P for trend=0.008) was observed, and was similar for men and women.
IBD affects about 3.1 million people in the U.S. and 1.3 million in Europe, with incidence rising globally, especially among newly industrialized countries, Khalili’s group said. IBD is associated with an annual healthcare cost of $23,000 per patient in the U.S., and there are no current strategies to prevent the development of IBD. While one approach to preventing many chronic diseases is modification of lifestyle and dietary factors, the success of adhering to such changes remains unclear.
For this study, Khalili and colleagues examined data on 72,290 participants from the NHS, 93,909 from the NHS II, and 41,871 from the HPFS. The NHS enrolled female nurses ages 30 to 55 across 11 states in 1976. NHS II assessed a slightly younger cohort of female nurses (ages 25 to 42) from 15 states starting in 1989, while the HPFS enrolled male physicians ages 40 to 75 across all states in 1986.
In order to externally validate their findings, the researchers assessed data on 40,810 participants in the Cohort of Swedish Men, 404,144 from the European Prospective Investigation into Cancer and Nutrition, and 37,275 from the Swedish Mammography Cohort.
Using participant baseline and biennial questionnaires that assessed lifestyle factors, anthropomorphic data, and medical history, Khalili and colleagues developed modifiable risk scores ranging from 0 to 6 for Crohn’s disease and ulcerative colitis, with higher scores indicating more risk factors. Healthy lifestyle scores ranging from 0 to 9 were also developed, based on recommendations from the American Heart Association and other organizations, with higher scores indicating a healthier lifestyle.
A healthy lifestyle included never smoking, a BMI between 18.5 and 25, and engaging in physical activity of at least 7.5 metabolic equivalent of task-hours per week, in addition to consuming less than half a serving of red meat per day, at least eight daily servings of fruit/vegetables, at least half a serving of nuts or seeds per day, at least two servings of fish per week, at least 25 g of daily fiber, and a maximum of one daily alcoholic beverage for women and two for men.
Across 5,117,021 person-years of follow-up, 346 cases of Crohn’s disease and 456 cases of ulcerative colitis were reported.
On falsification analysis, adherence to low-risk factors for Crohn’s disease could have also prevented 32.3% of cases of rheumatoid arthritis, 13.3% of cases of colorectal cancer, and 14% of cases of cardiovascular disease, though this was not the case for ulcerative colitis.
“This is largely due to differences in strength of associations and prevalence of risk factors, and presence of other modifiable risk factors such as alcohol and medications or supplements which are strongly associated with these other conditions,” Khalili and colleagues suggested.
They acknowledged that younger-onset IBD was under-represented in their study, since the mean age of the cohort (about 45) was higher than the usual age at onset of IBD. In addition, data on other modifiable risk factors such as stress were not explored, and high-risk individuals were not assessed.
Zaina Hamza is a staff writer for MedPage Today, covering Gastroenterology and Infectious disease. She is based in Chicago.
Disclosures
This study was primarily supported by the National Institutes of Health.
Khalili reported support from the American College of Gastroenterology Senior Research Award and the Beker Foundation, as well as consulting fees from AbbVie and Takeda, and grant funding from Pfizer and Takeda.
Co-authors also reported multiple relationships with industry.
In a series of experiments, scientists at Harvard-affiliated Beth Israel Deaconess Medical found that patients with severe COVID-19 exhibit a drop in cognitive performance that mimics accelerated aging.
Primarily a respiratory disease, neurological symptoms have been described in many COVID-19 patients, including in recovered individuals. Patients report symptoms including brain fog or lack of focused thinking, memory loss, and depression.
The team’s analysis, published in Nature Aging, suggested that many biological pathways that change with natural aging in the brain also changed in patients with severe COVID-19.
“Ours is the first study to show that COVID-19 is associated with the molecular signatures of brain aging,” said co-first and co-corresponding author Maria Mavrikaki, an instructor of pathology at BIDMC and Harvard Medical School. “We found striking similarities between the brains of patients with COVID-19 and aged individuals.”
Using RNA sequencing to measure the levels of every gene expressed in a particular tissue sample, the scientists assessed changes in gene expression profiles in the brains of COVID-19 patients and compared them to those changes observed in the brains of uninfected individuals.
Mavrikaki and colleagues analyzed a total of 54 postmortem human frontal cortex tissue samples from adults 22 to 85 years old. Of these, 21 samples were from severe COVID-19 patients and one from an asymptomatic COVID-19 patient who died. These samples were age- and sex-matched to uninfected controls with no history of neurological or psychiatric disease. The scientists also included an age-and sex- matched uninfected Alzheimer’s disease case for analysis as a control to a COVID-19 case which had co-morbid Alzheimer’s disease, as well as an additional independent control group of uninfected individuals with a history of intensive care or ventilator treatment.
“We observed that gene expression in the brain tissue of patients who died of COVID-19 closely resembled that of uninfected individuals 71 years old or older,” said co-first author Jonathan Lee, a postdoctoral research fellow at BIDMC and Harvard Medical School. “Genes that were upregulated in aging were upregulated in the context of severe COVID-19; likewise, genes downregulated in aging were also downregulated in severe COVID-19.
“While we did not find evidence that the SARS-CoV-2 virus was present in the brain tissue at the time of death, we discovered inflammatory patterns associated with COVID-19. This suggests that this inflammation may contribute to the aging-like effects observed in the brains of patients with COVID-19 and long COVID,” Lee added.
“Given these findings, we advocate for neurological follow-up of recovered COVID-19 patients,” said senior and co-corresponding author Frank Slack, director of the Institute for RNA Medicine at BIDMC and the Shields Warren Mallinckrodt Professor of Medical Research at Harvard Medical School. “We also emphasize the potential clinical value in modifying the factors associated with the risk of dementia — such as controlling weight and reducing excessive alcohol consumption — to reduce the risk or delay the development of aging-related neurological pathologies and cognitive decline.”
Better understanding of the molecular mechanisms underlying brain aging and cognitive decline in COVID-19 could lead to the development of novel therapeutics to address cognitive decline observed in COVID-19 patients. The team is now trying to understand what drives the aging-like effects in the brains of COVID-19 patients.
Isaac H. Solomon of Brigham and Women’s Hospital, also contributed to this work, which was supported by the National Institute of Aging (NIA; R01 AG058816).
The statistics are repeated again and again in news coverage of the youth mental health crisis, but they’re no less startling: The number of children living with depression and anxiety reportedly doubled during the pandemic.
With the number of stresses bearing down on young people today — the climate crisis, social isolation, pressure to succeed, and so many others for kids with marginalized identities — I don’t find this surprising. But I also think we have a cultural tendency to become numb to this kind of information because it’s so overwhelmingly troubling.
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If you’re a parent, this rise in emotional distress among children may feel like a vague and shadowy boogeyman, especially if you aren’t sure of what signs to look out for in your own kiddos.
One reader asked us: Do depression and anxiety look different in kids than in adults?
The short answer is — kind of. There is more similarity than difference in the way anxiety and depression present in kids and adults, but there are some nuances. I thought it would be helpful to lay out what these conditions can look like for children and teens, and how you can support your kids if they’re struggling in these ways.
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You’ll notice that there’s some overlap in how anxiety and depression present in children, and they often co-occur in both adults and children. That’s because these conditions share many of the same risk factors, including environmental stressors and traumatic experiences. Someone who has an anxiety disorder is more likely to be depressed, and vice versa. Also, psychologists invented these categories to organize symptoms into diagnosable mental disorders, so they’re imperfect and sometimes reduce complex problems into labels (an issue I’d like to explore in a future newsletter).
I also want to note that almost everyone feels depressed or anxious at different points in their lives, including kids. But when feeling bad gets in the way of kids living full and meaningful lives, they may be dealing with something more. My goal here isn’t to help you diagnose your little ones, but instead to help you notice patterns that might be out of the ordinary so that you can be there for them.
Depression in kids
Here are some signs of depression to look out for in your kids, according to this week’s experts:
Changes in mood: Frequent crying or sadness may also be a symptom of depression but doesn’t always appear in kids, said Judy Garber, professor of psychology and human development at Vanderbilt University.
The biggest difference in how depression presents in children versus adults is that, instead of appearing sad, kids struggling with depression can often seem irritable or cranky.
This can be tricky when we’re talking about teens in particular, said Jocelyn Carter, professor of pediatric psychology at DePaul University.
“The stereotype is that a lot of teens are grouchy or easily irritable. The kind of grouchiness associated with depression would be a change from their normal personality or way of interacting with the world,” Carter told me. “They might appear irritable most of the day, not just when you ask them to do something they don’t want to do.”
Changes in sleep and appetite: Fluctuations in sleep patterns are normal, but when the changes are significant — sleeping a lot less or a lot more — it could be cause for concern.
Sleeping in late, or staying up late and being tired during the next school day, is pretty common for teenagers, so such sudden changes would need to be accompanied by some of these other shifts in behavior I’m listing.
“You might ask your kid, ‘How have you been sleeping? Have you had any problems falling asleep? Have you been waking up and can’t fall back asleep?’” Garber recommended.
You might also notice that your child is eating more or less than usual. For example, you make their favorite meal and they don’t want it. Or if they’re eating more than usual, that change isn’t related to being more physically active or having a growth spurt, Garber said.
Less energy: “I’ve never met a teen that wasn’t tired,” Garber joked. But fatigue becomes an issue, she said, when their energy levels are so low that they aren’t hanging out with friends or doing their homework because they’re too tired.
Loss of interest in activities they usually enjoy: Kids who are depressed might withdraw socially from friends or their usual hobbies. Younger children might play with their toys less or engage in more solitary behaviors away from other kids, Garber said.
If teens stop hanging out with their friends, they don’t have anyone they consider to be a close friend, or if they suddenly stop using social media and texting, you should check in with them, she added.
Teens, of course, drop interests and pick up new ones all the time.
“It’s fine if someone isn’t playing five sports and an instrument, but there are some kids for whom nothing seems to really work,” said Stanley Markowski, a clinical psychologist in Oakland who works with kids and teens. “They can’t seem to push over that hump — the growing pains of being in the discomfort of trying something new.”
Also, this is a generalization and a product of socialization, but teen boys may be more likely to say, “I don’t care” or “I don’t feel like it,” rather than directly telling you that they’re sad, Garber said.
Feeling bad about themselves: Kids struggling with depression often feel like they can’t do anything right or that no one likes them. “Little kids might say that no one wants to be their friends,” Garber said, “or they’re no good at school and they might as well not try.”
Difficulty concentrating: If your child isn’t able to get their schoolwork done (above and beyond what that usually looks like for them), their mind is constantly wandering and they’re experiencing some of these other symptoms, it could be a symptom of depression, Garber said.
Other considerations: Instead of going inward and withdrawing, some kids externalize their depression, Markowski said. This can look like being mean to their peers or parents, or acting out in other ways. “Boys especially,” he said, “might try to overcompensate for feelings of sadness and vulnerability, and instead act as if they’re invincible.”
Anxiety in kids
As I mentioned earlier, anxiety and depression share some symptoms. Changes in sleeping and eating, irritability, and difficulty concentrating are also signs of anxiety. Beyond that, here is what anxiety may look like in kids:
Frequent worrying: Kids with anxiety are often worried all the time, and it’s hard to make it stop. What they worry about will vary from child to child. They might be preoccupied with something bad happening in the future to themselves or their family.
“Kids with anxiety may want guarantees of safety, that bad things won’t happen,” Carter said.
”One of the things I love about children is that they have a lot of great questions. For most kids, if they’re a little scared or nervous about driving over a bridge, they might ask us what would happen if the bridge collapsed while we drove over it. We could say, ‘That would be bad, but structural engineers work on bridges to make sure we’re safe.’ A kid without anxiety would accept that. A child more prone to anxiety would have many more follow-up questions, be in a lot of distress as you’re driving over it, or refuse to be in the car as you’re driving over it.”
Worry can sometimes show up as separation anxiety in younger kiddos, Garber said, whereas older children and teenagers tend to worry more about school or have social anxiety. They might not go to parties or try out for a team, or never raise their hand in class.
Physical behaviors and symptoms: Anxious kids might pick or bite their nails, or complain of stomachaches and headaches, Markowski said. Older kids might also experience muscle tension or pain in their limbs and back.
In some Latinx and Asian cultures, kids may be more likely to talk about their anxiety symptoms as these sensations in the body. “It’s thought that, within those cultures,” Carter said, “it’s more culturally relevant and less stigmatizing to be talking about a bodily expression of these emotional states rather than emotions directly.”
Other considerations: Garber noted that anxiety tends to be more constant, while depression comes and goes.
How you can help
It’s normal to feel scared and maybe even a little helpless when you can see that your child is struggling. But there’s a lot you can do as a parent to help your kids manage and understand what’s going on.
First off, it’s important to normalize anxiety, depression and difficult feelings.
“Let them know that everyone experiences stress, and many people experience anxiety,” Garber said. “You can tell them that depression is a little less common but that it’s treatable and doesn’t have to last forever.” When you’re anxious or sad, model what it looks like to work through those feelings.
And it might seem obvious, but having these conversations in a warm and accepting way is vital. Let them talk, don’t judge, and don’t tell them what to do. Just listen and don’t try to fix things, Garber said.
“Reflect back on how they’re feeling,” she added. “Say, ‘That’s really hard, and I can understand why you’re feeling that way.’”
Encouraging kids to get involved in fun activities that connect them to other kids and their own creativity can help them cope.
“Movement, a sense of community and learning new skills in a different environment,” Carter said, “can really boost a kid’s self-esteem and sense of competence.”
If these symptoms are affecting your child’s functioning at home, at school or in their relationships, it may be time to get the help of a mental health professional, experts told me. If they’re having thoughts of killing themselves or are self-harming, seek medical attention immediately.
“In general, it’s better to look at it earlier before it grows,” Markowski said. “Kids are good at hiding stuff. Sometimes we don’t know it’s a problem until it’s pretty big. Getting a professional opinion will let you know whether it’s developmental or something a bit more concerning.”
Kids can be so resilient. But they need our support, warmth and attention.
Until next week,
Laura
If what you learned today from these experts spoke to you or you’d like to tell us about your own experiences, please email us and let us know if it is OK to share your thoughts with the larger Group Therapy community. The email GroupTherapy@latimes.com gets right to our team. As always, find us on Instagram at @latimesforyourmind, where we’ll continue this conversation. See previous editions here.
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More perspectives on today’s topic & other resources
In this episode of “Head-Lines,” The Times’ mental health puppet show, kids can learn more about social anxiety and what that looks and feels like. If you want to keep the conversation going, there’s an accompanying discussion guide for parents, with suggestions for how to talk with your kids about anxiety.
What to do (and not do) when children are anxious, according to the Child Mind Institute. This guide addresses the best way for parents to respond to an anxious child, how kids can learn to tolerate anxiety, and how parents can help kids stay calm in stressful situations.
The Child Mind Institute also has great resources for parents with children struggling with depression, including what to do if you think your teen is depressed, and how to help kids who are too hard on themselves.
Other interesting stuff
The implications of the debate over whether “extreme racism” is a mental illness. If extreme racism were to become accepted as a mental illness, more suspects in hate-crime cases could potentially have recourse to mount “insanity” defenses in court.
Developing nations have been serving as a proving ground for a model called community-based care, where lightly trained laypeople — someone like your grandmother, not a doctor — deliver brief mental health interventions in informal settings like homes or parks. The U.S. is taking note.
Group Therapy is for informational purposes only and is not a substitute for professional mental health advice, diagnosis or treatment. We encourage you to seek the advice of a mental health professional or other qualified health provider with any questions or concerns you may have about your mental health.
Cardiovascular disease is the leading cause of death in the U.S. and around the world. Though it’s held the top spot for decades, it wasn’t always the king of mortal maladies. Its ascension was propelled by two of medical science’s greatest successes.
“Before the 20th century, heart disease was an uncommon cause of death,” says Dr. Michael Shapiro, a professor of cardiology at the Wake Forest University School of Medicine. Bacterial infections such as tuberculosis and dysentery, as well as smallpox and other contagious viruses, were common killers. “Antibiotics and vaccines changed everything.”
Some experts believe that gene editing using CRISPR technologies could be medical science’s next big breakthrough—an advancement that allows the human race to smash through the longevity ceiling imposed by heart disease, and maybe also other common killers. One day, hopefully, “CRISPR technology could be used to treat many conditions, for example neurological disease, cancers, and cardiovascular disease,” says Dr. Qiaobing Xu, a gene-editing researcher and professor of biomedical engineering at Tufts University.
Perhaps the most tantalizing of these applications involves lowering cholesterol, specifically the “bad” kind: low-density lipoprotein (LDL) cholesterol. “While cholesterol is an essential molecule for myriad biological processes, if blood levels of LDL cholesterol get too high, the cholesterol can accumulate on the walls of the arteries, forming congestive deposits known as plaques,” Shapiro says. These plaques directly cause or contribute to many forms of cardiovascular disease. “Managing cholesterol is a huge part of my job as a cardiologist focused on prevention.”
While a poor diet, stress, lack of exercise, and other lifestyle factors can lead to cholesterol problems, genetic factors also play a role. Some genes that regulate blood levels of LDL cholesterol appear to be good targets for CRISPR gene-editing technologies. Already, research in non-human primates has found that editing cholesterol genes appears to be both safe and effective for the mitigation of cardiovascular disease. And, earlier this year, the first human underwent gene editing for the treatment of high cholesterol.
The science underlying CRISPR and gene editing for LDL cholesterol is rapidly advancing. However, some major hurdles remain, and experts warn of the potential for unanticipated risks.
The science of gene editing for cholesterol
CRISPR is an acronym for clustered regularly interspaced short palindromic repeats. These are segments of DNA found in some types of bacteria. These segments act like storage containers for snippets of genetic material cut from defeated viral pathogens. The bacteria store these snippets in order to enhance their innate immunity from future threats.
During the past decade, researchers have figured out how to harness these CRISPR-related biological processes to edit the genetic material of living organisms, including people. “Gene editing involves two pieces,” Xu says. There’s an endonuclease—an enzyme—that performs the genetic alteration, and there’s also a guide RNA that ensures the endonuclease is only working on the desired part of the genome. “You put those two pieces together, and you can modify the genome,” he says.
Sometimes a third piece is necessary: As Xu says, some forms of gene editing are done ex vivo, or outside the body. The relevant cells are removed and genetically modified in a lab. They’re then put back into the same person so that they can multiply and displace the old unedited cell type. This ex vivo process can be used to change the genetic material of blood cells, for example, and has been utilized to treat conditions such as sickle cell disease.
But a second, more complex method of gene editing involves in vivo alterations to a person’s genetic material. This is necessary when the relevant material cannot be removed—for example, when it’s housed in an organ. In these instances, a delivery vehicle is needed to safely carry the injected CRISPR technology to the correct location inside the human body. Xu was part of a team that published groundbreaking research in 2021 in the Proceedings of the National Academy of Sciences. That research identified a specific type of lipid nanoparticle that could carry CRISPR gene-editing material specifically to the liver, which is the site of the modifications needed to address cholesterol problems.
The ability to edit genetic material is only useful if you’ve identified DNA sequences or mutations that directly contribute to the development of health problems. In the case of LDL cholesterol, researchers believe they’ve identified two such targets. The discovery of those involved nifty deductions that would make Sherlock Holmes proud.
“About 20 years ago, there was a research group in France that was studying a number of French families that had a relatively common inherited condition called familial hypercholesterolemia, or FH,” Shapiro says. People with FH have unusually high levels of LDL cholesterol from birth and, as a consequence, are at high risk for premature cardiovascular disease. However, the French kindred did not have any mutations in the known FH genes. The French researchers, working with another team in Montreal, Canada, identified a specific problem mutation in this kindred. The mutation causes a protein known as PCSK9 to bind to receptors that would normally help remove LDL cholesterol from the blood. “The vast majority of the time, mutations make a protein that a gene encodes for less effective, and this is called a loss-of-function mutation,” he says. “But in this French kindred, it turned out that the PCSK9 gene mutation was a gain-of-function mutation.”
Because such mutations are uncommon, researchers who looked at this work theorized that some people might be born with its opposite—that is, a loss-of-function mutation on the PCSK9 gene. Theoretically, such a mutation would lower levels of blood cholesterol and cardiovascular disease. “They looked for this in large populations, and sure enough, they found a naturally occurring loss-of-function mutation that reduces LDL cholesterol and makes people almost immune to atherosclerosis,” Shapiro says.
The discovery of the PCSK9 gene and the protein’s role in hypercholesterolemia led to the development of PCSK9 inhibitors, a class of cholesterol drugs designed to limit PCSK9 activity. But this discovery also provided a perfect target for CRISPR gene-editing therapies. Here was a mutation that occurs naturally, and that lowers LDL cholesterol. Just as importantly, the mutation wasn’t associated with any known health problems. All of this suggests that using CRISPR technologies to make such a modification could be both safe and effective. “Researchers saw all this with the PCSK9 gene and started saying yes, CRISPR therapy makes sense,” he says.
Researchers, including Xu, have since identified a second gene—Angptl3—that plays an important role in regulating blood levels of cholesterol and triglycerides. “If we can knock down both of those two proteins—PCSK9 and Angptl3—that should lead to lower lipid and cholesterol levels in plasma, and that can decrease the risk of cardiovascular disease,” Xu says.
Thus far, the research on CRISPR and its cholesterol-lowering genetic targets has been nothing short of revolutionary. Most observers applaud the science and express enthusiasm about its possibilities. But most also temper their enthusiasm with realism—and some concerns.
“One of the big challenges is going to be proving safety and specificity in humans,” says Dr. Christie Ballantyne, chief of cardiology and cardiovascular research at Baylor College of Medicine. “You’re talking about making a permanent change to someone’s DNA, and there are concerns that any negative effects may take a long time to show up.”
The initial clinical trials (including those already planned or in progress) will include people with serious inherited cholesterol disorders—cases where the pros and cons clearly favor gene-editing therapy. However, the big hope is that this treatment could eventually be performed as a preventive measure—before someone has lived for years or decades with elevated levels of cholesterol. That means going inside a relatively healthy person and performing fine-tuned work on very specific parts of their DNA. In essence, it’s like putting out a small fire that is likely to spread—but hasn’t spread yet. And any time you play with fire, someone may get burned. “You need to specifically silence some genes and not others, which is not easy,” Xu says. “Caution is needed, and the concerns people have are valid.”
Even if all the promising research pans out and the therapy works, there are reasons to question how broadly it will be embraced.
“We already have some monoclonal antibody therapies that target PCSK9 that are very effective,” Ballantyne says. Statins, which for years have been the go-to treatment for people with moderate or severe cholesterol problems, have also proven to be both safe and effective. They’re also cheap. (Shapiro advocates for their wider deployment. “There’s a lot of misinformation out there on statins,” he says. “While they can cause nuisance side-effects like muscle aches and pain in a minority of patients, they’re one of the most scrutinized drugs, and they’ve turned out to be extremely safe.”)
“Let’s say you’re 40, your cholesterol is really high, and your choice is between a statin that’s supported by studies with hundreds of thousands of users, or gene editing, which will permanently change something in your liver,” Ballantyne says. “I think most people are going to pick the statin.”
On the other hand, one of the biggest issues with the cholesterol drugs we have today is that, even though they work, some people won’t take them. “I can’t even get some people who have had a heart attack to stay on statins,” Shapiro says. “About 50% of users stop taking them within a year, and after five years, only about 5% of users are still on them.”
The issue of poor medication adherence is a common and intractable one throughout the field of medicine. There’s reason to believe that if people were convinced of its safety, a one-time gene-editing treatment would be very appealing when compared to taking a daily pill for the rest of their lives.
Almost across the board, experts say that gene-editing therapy is likely here to stay. “It’s great science, and I think the technology is going to happen,” Ballantyne says.
He recalls that, when he was in medical school, monoclonal antibody therapy was the hot new thing. Back then it had plenty of naysayers, but they were silenced long ago. “It took a couple decades and there were problems along the way, but now it’s everywhere.” He thinks gene editing is likely to follow a similar path.
However, Ballantyne says that cholesterol may prove more resistant to CRISPR-based treatments than some other medical conditions. “If someone has a lethal genetic disease with no treatment, that’s a more straightforward risk-benefit calculation,” he says. “With cholesterol, I think that might not be such an easy shot on goal.”
Solving health problems through fitness and nutrition
Approaches to resistance training that build muscle mass and bone density without contributing to injury
How busy people can get great resistance training in a short amount of time
The sweet spot between pushing too hard in the gym and not working hard enough
What to do in the 23 hours outside the gym to make the most of your health and fitness journey
Show notes:
Hey, everybody, Chris Kresser here. Welcome to another episode of Revolution Health Radio. Over the last few months, I’ve received a lot of requests for more fitness and performance-oriented podcasts, so I’m really excited to welcome Marcus Filly as my guest.
You may have heard of him if you’re in the functional movement space. He’s the creator of Functional Bodybuilding and a former six-time CrossFit Games athlete with decades of experience coaching and designing both individual and group training programs. Marcus was very active in the CrossFit community, but after suffering from burnout and injury, he developed a new type of training that blends bodybuilding with functional movement. I’m really excited to talk to Marcus about this. We’re going to dive into approaches to resistance training that build muscle mass and bone density without contributing to injury, how busy people can [fit] great resistance training workouts in a very short amount of time, the sweet spot between pushing too hard in the gym, which can lead to injury and burnout, and not working hard enough, and what to do in the 23 hours outside of the gym to make the most of your health and fitness journey. I really enjoyed this conversation. I think you will, as well. Let’s dive in.
Chris Kresser: Marcus, welcome to the show. It’s great to have you.
Marcus Filly: Thank you very much for having me. I wanted to say that, first and foremost, I’ve been following you for a long time. So to have the opportunity to come and speak to you and share something that I do with your audience, it’s a true pleasure. I really appreciate it.
Chris Kresser: You’re very welcome. I’m really looking forward to talking to you about this because I’ve never been in CrossFit myself, but I have [had] a lot of patients over the years who’ve been pretty active in CrossFit. I know it can be a powerful and positive experience for so many people, and I also know that there can be a dark side, or things can go wrong, let’s say. I’ve had a number of patients over the years who got into CrossFit for all the right reasons. They wanted to get more exercise and be fit, they love the community aspect of it, and [they love] the challenge. I think CrossFit is so good at that—people pushing each other to their limits and really supporting one another. But they were wrecked. They had severe [hypothalamic–pituitary–adrenal] axis dysregulation, [their] cortisol and [dehydroepiandrosterone] (DHEA) were in the tank, [and] they were experiencing a lot of symptoms of overtraining. I know you have your own personal history here. You’re a very accomplished CrossFit athlete. You reached a very high level in that world, and then something happened. Walk us through that, just a little bit about your background and your relationship with CrossFit and that [type] of physical activity.
Marcus Filly: [I’m] happy to share a little bit about my story. [I’ll] start by saying that I was a CrossFit coach and CrossFit affiliate owner for about eight years, starting in 2009 [or] 2010. That’s what I devoted a lot of my life to. Principally, I was a coach and trying to build a fitness coaching business [and] a career helping people get better. At the same time, I also started to compete in the sport of CrossFit. I think [that in] those early years of coaching and competing, one of the biggest challenges that faced the community was that the two were getting closely linked together—coaching [the] general population and competing in a sport, trying to win points. The intention behind both should be different; however, they were getting overlapped and the lines were very unclear. It was very blurry. If you want to play [recreational] sports, you don’t train like you’re in the NFL, right? And vice versa. You’ve got to have a clear understanding of what physical activity [is], what’s here to get somebody healthy and strong, and then what is here to push the limits of human performance.
I didn’t really know any of that until much later on, [after] having seen examples of myself and clients pushing too far. My career in the sport of CrossFit was on an upward trajectory for seven years until 2016, when I finished 12th in the worldwide CrossFit Games. [I] had my best season and performance of my life and had reached what I thought was the peak and the pinnacle of my CrossFit career. And I could see going forward that I didn’t have room to keep pushing the limits of this. Because, and many people [who] were in the CrossFit community [can attest to this], a 2016 CrossFit Games athlete [who’s] close to the top 10 in the world is [maybe] going to earn $15,000 total on the year from earnings. You’re not a professional athlete. You’re a recreational athlete [who’s] pushing your body like a professional athlete.
So I had to do all the other things outside of my sport to stay growing as a person [and] in my career. I’m getting married, [I] want to have a family, [and] we want to have kids. I needed to build something else. When you push yourself physically and you’re also pushing yourself in your career and [with] the time constraints, something has to give. And typically, [it’s] the body. The body just starts to shut down. Like you mentioned, people’s hormones [are] out of whack, [and their] energy levels [are] not optimized. Something just starts to feel off. My experience, trying to push as a professional athlete but also build a business and build a family and do a bunch of other things, was very similar to that of my clients who came to me already overstressed with a poor nutrition profile [and] not in a good movement practice. Maybe they had kids in the last two to five years and they’re adjusting to being parents, [or] they work very demanding jobs, the list goes on. Then we hit them with, “Hey, go high intensity four or five days a week with your physical movement; that’s going to solve all your problems.” Well, it solved some things, but it [also] added to their stress profile and compounded certain problems, six months, 12 months, 18 months, 24 months later for them.
This was the awakening for me where it was like, “Okay, I love this sport, I love this community, I love these movements, [and] I love this way of training. And I don’t want to go back to doing something totally different and less interesting and less functional.” I couldn’t see myself regressing back to the way I trained a decade earlier, where it was three sets of 10, biceps, triceps, elliptical. No way. This is way more interesting, way more compelling, and way more motivating and inspiring. And there’s something about the way I’m approaching it from, “I want to be the best and push myself and always win the time trial.” There’s something about that approach that’s clearly not conducive to long-term wellness, especially with a movement practice like this. So how do I navigate away from that without losing the essence of, “I want to move functionally, I want to build strength, [and] I want to challenge myself.” These are things that have to be central to any movement practice. Otherwise, you will not get stronger and feel better. You will, over time, feel worse, get weaker, [and] have atrophy—things that we don’t want.
This was what inspired the change in how I was going to approach being a coach and an athlete and what spawned the next phase of my career, which was moving away from [the] CrossFit brand [and] starting my own business in what is now called Functional Bodybuilding. That’s the way we train, to solve this question that was there.
Chris Kresser: Great. I definitely want to dive in more to what Functional Bodybuilding is and get into the details of what that looks like. Before we do that, I want to linger a little bit on some of the challenges that you faced personally, and also saw your clients facing as a CrossFit coach and a CrossFit athlete. [I’m] not here to bash CrossFit. Like I said, I have a ton of respect for it. I think it helps a lot of people, and there’s a lot of positive things about it. I’ve spoken to many, many CrossFit gym owners and people I know who were heavily involved in the CrossFit community, [and] their views of how that should be approached have evolved over time. If we take the standard CrossFit programming, maybe we could say the old-school CrossFit way, what’s the problem with that? What are the risks for people who are just getting into that, and what should people watch out for?
Marcus Filly: Yeah, that’s a good starting place for the discussion. I also want to say that I have the same feelings about CrossFit. I have a tremendous amount of love and respect and appreciation for what [it] did for me and my career and getting me started, and I still see there’s a lot of value to that community and what people are building in their gyms. One of the main challenges that people face when they’re starting an exercise program, or training, or learning about proper training, is teaching themselves how to push their effort sufficiently [enough] that they start to see change. There [are] more people out there in the world [who] are exercising and not really working that hard, and I want to applaud them for getting in movement and just moving, but they expect to see all these benefits and they’re afraid to go and push themselves hard. It’s fearful, it’s scary, and it’s just flat-out difficult to go in and lift weights and push close to failure. Not failure, but to push yourself. It doesn’t feel great to do interval sprints on a bike. You don’t love it right away. Most people do not love it right away.
You’ve got a lot of people exercising and not getting results. They’re like, “What’s going on?” It’s like, “Well, you need to work a little harder.” And it’s hard to teach people that. CrossFit kind of had this new tool. It’s like, “I can’t seem to get this nail to go in with this really flimsy hammer.” “Oh, well here’s a powerful hammer that can hammer hundreds of nails in two seconds. Here’s this new tool. Go ahead.” That’s what CrossFit was to people. They [showed] up, and it packed a powerful amount of intensity into a short amount of time, [and] people learned very quickly how to overcome this challenge of not working hard enough. We put people through one of the most straightforward CrossFit workouts on their first day. You row 500 meters, you do 40 squats, you do 30 sit-ups, 20 push-ups, and 10 pull-ups. You’re told [to] do this as fast as you can, but you’ve got to hit your range of motion, [and] you’ve got to do the full reps. And this put 85 percent of people flat on their back. They would stand [up], and the thought that went through [their] minds was, “Holy crap, I’ve never done anything this hard in my life, and that took seven minutes. Whoa.”
CrossFit brought a lot of intensity in its essence [and] its original form. And [it] used some very simple principles to get there—choose the right movements, choose the right weights that allow people to move with a decent amount of power but quickly, and organize the workout structure, the repetitions, the sets, the reps, in a way where people don’t have to slow down and take long breaks. They can just keep going, and they build this massive momentum of intensity without knowing it. Now, when people get exposed to this, they’re like, “Great, I’ve got the solution. I can work hard in 10 minutes and get all these results.” They start to see change. Their bodies are like, “Whoa, this was a massive stress. I have to adapt to this.” We’re resilient humans, so initially, people’s bodies start to get stronger, [they] lose weight, [they] feel more energetic, [they] do whatever it takes because tomorrow, [they’ve] got to show up and do this crazy thing at the gym again. [They think,] “I better make some changes. I better upregulate whatever metabolic pathway is helping me utilize energy better for this sprint, [or] this attack that I’m going through.” So this is good on the front end.
But as people start to develop a bit more fitness and they’re able to push more through these workouts, we start to add in some complexity of movement. And people don’t have these physical positions, or they don’t have the requisite time and energy and knowledge to recover from those events, or they don’t have the space in their life to recover from it. If you go to battle for 15 minutes, what should you do for the next four hours? You should go and [lie] underneath [a] tree and just recover. But they don’t do that. They jump in their car, they commute to their job, they’re drinking a bunch of coffee to keep them going because they’re tired but they’ve got meetings, they skip lunch, they didn’t get a good night’s sleep, [and] they’re not doing any of the things that are required to keep them healthy and recovering from these acute bouts of stress. Not to mention that now we’re starting to exercise or train at a level of intensity where there’s not a lot of room for error anymore. If you move incorrectly going 100 miles per hour, your knees are going to tweak out. If you move incorrectly at five miles per hour, you just have a little wobble and you can course correct.
Chris Kresser: And there’s another factor all along here, which is both a pro and a con of CrossFit, that there are a bunch of people around cheering you on, watching, [and] supporting you. As human beings, we are competitive by nature, and we don’t want to fall short in front of our peers. So that’s a whole other influence that’s operating during this time.
Marcus Filly: Yeah, absolutely. And, hey, I want to be in a room of people cheering for me when I’m on the assault bike and trying to push myself and the room for error is pretty big. I’m not going to get hurt by pedaling too hard. But if I’ve got a roomful of people cheering me on for a maximum snatch, which is a very complex Olympic weightlifting movement, I’m gonna drum up some extra energy [and] lift [the] extra 10 pounds that I would have never lifted [if] I didn’t have this room in front of me. But I didn’t catch it well, the bar fell on my head, and now I’ve got this contusion. I’ve maybe tweaked my C4 [or] C5 disc. That was not the situation [where] I wanted to be pumped up and cheered for. It’s just a Tuesday at the local gym. I’ve got to go to work. That wasn’t what I was looking for.
So [like] you said, the pros also became the cons. We have this way of delivering a lot of intensity to get people to do hard work that they otherwise [would] have shied away from or never were able to access. That’s a good thing. But at the same time, that intensity potentially introduced risk that we have never encountered in the gym. Most people who are looking for general fitness don’t need to be encountering that kind of risk.
Chris Kresser: What were the typical responses that you saw? I think one of the things that can happen, [and] this is not just true for starting an exercise or fitness program, it’s also true when people start special diets or new supplements or things like that, there’s an initial period of feeling better and then, over time, feeling worse [happens] gradually. Sometimes so gradually that it’s difficult for people to even track what’s happening. And when that person starts to reflect on why [they’re] feeling so much worse now, they don’t think about whatever it was that they started six months ago, because when they started it, they felt better. There’s now an association in their mind between whatever that thing was and feeling better, and they therefore don’t become aware that [the] same thing that initially made them feel better [is now making them] feel worse. One thing that I’ve found can be helpful with my patients is just [telling] them some of the things that can happen in that situation. What are some of the symptoms [and] the signs? As a coach, what did you look out for in your clients or in people who are coming to you from other situations? What were the typical symptoms or responses, other than the obvious injury or something like that, that you saw in people who were overtraining?
Marcus Filly: Well, it’s a good question. When I was in the mix of it all, I was not proactively looking at and seeing the signs and thinking of solutions. I was very reactive. I was like, “Hey, you’ve been here for two years, and suddenly, things aren’t going well. You were the perfect client. I don’t know what’s happening.” I just saw that enough times to really be like, “Hey, I’m scratching my head. This doesn’t make sense. What’s going on?” I had some mentors at the time [who] were further along in their careers as coaches [who] could make sense of it from a scientific and physiological perspective and helped me understand a little bit of what was happening. I think when I arrived at the tail end of my career and started to transition to coaching in a different way, because I was speaking about it and welcoming a lot of people to come into my circle and say, “Hey, I have the same problems. I lost a tremendous amount of drive and energy to come to the gym and perform. I can’t bring myself to do the thing that you’re asking me to do,” this was a thread that I [heard from] so many customers. After a couple [of] years, I just didn’t want to race against the clock anymore. I just didn’t have it in me. I just wanted to go to the gym and lift weights. I didn’t want to go and do the metcon. That’s the super hard, fast, classic CrossFit conditioning workout that’s got running and kettlebell swings and burpees and all the things. So there’s this physical shutdown. My body’s just not feeling up for it.
The second part was [that] people [were] having a really hard time following basic nutritional prescriptions and programs. They didn’t have a good appetite control mechanism; the feedback loop on satiety [and] the decisions around what foods appeal to them started to get really out of whack. They were feeling like, “Man, I’ve been doing this thing, and I’m seeing negative changes in my body composition and how my body looks and feels as a result of [not being] able to bring a level of energy into my training. Therefore, my movement is suffering overall, I’m not moving as much, and I’m not moving with as much intention as I used to. I’m so depleted and my stress profile is so swayed toward overstressed that I can’t seem to navigate these sugar cravings that I’m having. I’m basically wanting to eat processed carbs and fat all the time. That’s hyperpalatable.” That combination was what I saw in a lot of people. What that looked like was, “I don’t feel energetic, and my body doesn’t look as good as I want it to look,” which is [why] people showed up at the gym originally. They came and they said, “I want to look better, [and] I want to [have] more energy.” So when the opposite is happening, people start to question their fitness program. “Why am I doing this? I look worse than I did last year. I had those initial six months of things getting better, but now, things are worse, and I don’t understand it.”
Chris Kresser: Yeah. That’s pretty similar to what I saw in patients. I would add [that] disrupted sleep and circadian rhythms was a major factor for most of them. They had big imbalances in cortisol and DHEA. I would see, in men, declines in testosterone or increases in sex hormone-binding globulin. So, a decrease in free testosterone. In women, I would see sex hormone imbalances, as well, [and] sometimes digestive issues because of the chronic activation of the sympathetic nervous system. So I think we’re tuning into a lot of the same issues.
Marcus Filly: By the way, those were my blood markers to a T when I wrapped up my competitive career.
Chris Kresser: Right. So you became aware of this, and it was impossible to ignore, at some point. And despite the fact that you’d invested a ton of time and energy and achieved a very high level in CrossFit, you decided to step away from that. [It] sounds like [you] tried to retain the best parts of it, the things that were most inspiring for you and most attractive for people who are drawn to CrossFit, in general, [like] the more dynamic and functional movements rather than just, like you said, three sets of 10 and [the] more traditional approach to weightlifting and strength training, [and] to do that in a way that would not only prevent, or at least greatly reduce, the risk of injury and mitigate some of the potential downsides of all of that overtraining, but in a way that people would still meet their original goals [of] getting stronger, getting fitter, [and] looking better, which is what drew them to [CrossFit] in the first place. How did you approach [the] process of thinking about it [and] designing it? I imagine [there was] a lot of experimentation and trial and error until you landed on what you’re doing now.
Marcus Filly: I think there were probably two main things that helped and [were] what I leaned on the most. The beauty that I saw in CrossFit, even from the early days, [and] what inspired me to join that community and get my start as a fitness coach in CrossFit, as opposed to any other avenues that I could have taken to coach fitness, was that for about a decade from when I was 15 to 25, I trained in gyms a lot. I was a gym guy, and I also played a lot of high-level sports. I was [always] doing things that were, to most people, obscure and [limited to] a very small group. I did power cleans, I back squatted, I liked to deadlift, I did all this stuff, and nobody ever wanted to do any of that. But suddenly, CrossFit made that stuff sexy. It made it cool. I go to this example just because when it started to happen, I was like, “This is the last group of people I ever thought would come to the gym and want to power clean and deadlift,” but it was my soccer moms that I was working with. These women are showing up at 9:30 a.m. after dropping [off] their kids, and they want to deadlift, and they’re learning power cleans, and they want to do this. They’re fired up about it.
Something [that] I knew for a decade before I ever got into CrossFit was that weight training is the recipe for most people to achieve the look and feel that they want in their bodies and their fitness. Yeah, cardiorespiratory fitness is important. I want people to do cardio, but I want people to get strong, and I want people to lift weights. I want people to do resistance training. You’re not going to get the same value from doing yoga or pilates. Those are valuable tools of fitness, [but] I want people to lift weights. The vast majority of people I know [who] lift weights with intention, before CrossFit, but they bodybuil[t] or did some type of strength training, they usually looked pretty darn good and they move well, and they could do a lot of stuff. Those of us who came into CrossFit and were in the first couple [of] years the best CrossFitters, ask any of them what they were doing, it’s like, “I was just bodybuilding [and] doing strength training for the last 10 years. And on day one, I could do all the fancy stuff.” So what is the best part of this whole thing? The best part of this whole thing is [that] it got people lifting weights. It took Olympic style weightlifting, which was an obscure sport, and made it mainstream. Not that we need everyone to clean and jerk and snatch. But it got people picking up weights off the ground. It got my mom to start doing resistance training. You’ve got people doing this stuff [who] would have otherwise never done it. Okay, cool; we got you weightlifting. Now let me tell you that if we keep weightlifting but we turn the volume down on the intensity and the burpees and the cardio while you’re doing the weight training, you can still get a ton of benefit. People who just resistance train with [a] good prescription feel and look amazing. So let’s keep that. Let’s keep that going. So number one was, we got people lifting weights. Let’s keep them lifting weights, but now, let’s implement some control around the intensity lever that we’ve been hammering for the last couple of years.
What if the secret to staying athletic and feeling good is not by stressing your body out with one punishing workout after the next, but rather knowing exactly when to push and when to pull back? Marcus Filly explains how you can use Functional Bodybuilding workouts to get confident and fit—and still have energy left over for the other things you love in life. #chriskresser #functionalbodybuilding
Marcus Filly: The second thing was, with that specific community, to teach this principle of “less is more.” There was a period, which I think about it differently these days, but back then, I had people come into my gym who were like, “Marcus, how do I do a double day? I want to start doing double days.” I’m like, “Jesse, you’re 42 and you’ve got two kids. I love that you want to move, but maybe double days is not what we need to be doing right now. What else is going on in your life where you feel like you need to get to the gym twice a day? Why aren’t you stoked to go out and do [another] activity?” Or, I don’t know, not to make judgments, but the body that you want, the feeling that you want, the athletic pursuit that you have, we can find that in less time, and you need to actually [do] a few less of those hard conditioning workouts. You need to tone it down a little bit, and then you’re going to succeed. And what was that about? Well, we had this phenomenon happening where people were like, “Okay, I did a little bit and I saw some results, and then I plateaued. So I’m going to do some more, and I’m going to see some results, but then I [will] plateau. The only way to get better is to do more.” What they weren’t realizing was that, in this effort to do more and more and more, they were not addressing other important health pursuits and markers and tools that they can change and mitigate in their life to see results. The more they trained, the crappier their diet got because they were like, “I just need to eat all this food, and I’m going to eat processed food. I need to get calories, and I need to get protein, [and] I need to get carbs.” The quality of their food choices [was] going down and down and down as they got more and more competitive and [started] training more and more and more. This was the case for me. At the end of my career, I [was] eating pints of ice cream on a daily basis next to my meat and vegetables and all the good things I was eating. I needed to supplement with a lot of sugar and a lot of processed food to get sufficient energy. So my food profile was not as good as it could have been, [or] as it is now when I train a third or a quarter of the amount.
In pursuing more and more and more and more, other factors [were] getting thrown way off. So that was the other thing, was teaching people, “Hey, if we do a little bit less, [but] we do it with a lot of great intention and we reserve that energy you would have spent going and doing another hour of cardio, let’s spend that hour planning out a good week of food choices. Let’s go and shop and be intentional about what you’re going to put into your kitchen, and maybe spend an hour prepping out a couple [of] key meals that fall at times of [the] day where you’re really strapped for time and you might otherwise reach for something that is of lower quality.” That hour that you didn’t do cardio just made a huge impact on your wellness and your health going forward for months and months and months. [I] started to lean into [this] a lot with the approach to training that we brought forward. While sticking to, “I’m still going to do some of the movements; I’m still going to own some of those really fun and engaging parts of CrossFit.” We’re going to get away from the time on the whiteboard being the most important thing, to instead [the most important thing] being the quality of the movement and reserving enough energy that you can dedicate to the other factors that influence your health every day, 24/7.
Chris Kresser: That’s interesting. I’ve been a huge fan of outdoor sports for my whole life. I grew up on the beach in Southern California, so I was surfing from a very early age. I would get up and surf before school and surf after school. Then later, [there] was also skiing and mountain biking, kayaking, stand up paddleboarding, etc. And again, there’s no right or wrong way to do things. People have different interests. I’m not saying that way is the best way. But for me, those were the activities that brought me so much joy and satisfaction, not only because of the activities themselves, but because that was [how] I connected with nature and got sun exposure, I often did them with other people, [and] they’re super fun. They satisfy so many different needs above and beyond just fitness and being in the gym. I’ve always approached training, strength training, things like that, as something that I do for my health but [also] something that I do to improve my athletic performance in these other areas and reduce the risk of injury, stay strong, etc.
I’ve sometimes [thought] that this is true with anything, where we can become hyper-focused, almost myopically focused, on one particular thing, and leave out a lot of other things that can be beneficial and helpful for us. I’ve often wondered in that context, when I’ve had a patient who’s like, “Yeah, let’s do two-a-days in the gym.” I’m like, “Maybe you could take a bike ride outside instead of that second one, or maybe [pick] up a new hobby or a sport,” because there are ways [in which] that stimulates the brain, learning different kinds of movements [and] different kinds of motor activity. I think that supports neuroplasticity in the brain, helps us slow down the aging process, and keep our brains sharp. I’m curious how you think about that with your clients, because it sounds like you have moved toward trying to shorten the time [commitment in the gym and] maximize the [return on investment]. Less time in the gym [and] more time for other things outside of the gym.
Marcus Filly: Well, as somebody who went through a phase of life where the gym was life and I wanted to be in there three [or] four hours a day, I got a tremendous amount of value out of that period of time. I grew as a person in ways that I wouldn’t have otherwise. I don’t know if I could have ever found and fostered other activities. So I hesitate to tell somebody, “Hey, you shouldn’t be in the gym [for] more hours, if that’s what you really want to do. But it’s more getting people to ask the question, “Is this really where [I] want to be?” What if I told you that in [one] hour, three or four days a week, you could have the body of your dreams and you could feel great and you could have great sex drive, and you could find a partner and love life? They’d be like, “Yeah, I’ll do that over 12 hours in the gym,” or they’re like, “No, I want to go to the gym, and I want to keep doing this thing because it’s super fun for me.”
Chris Kresser: Nothing wrong with that. That’s their choice.
Marcus Filly: That’s totally their choice. So it’s about asking that question [and] getting people to really evaluate the purpose and the goal of this thing. I’ve tried to pare the training back to less than what I do today, and I found that there is a threshold where I was like, “I just want to be at the gym. I don’t really want to go for a walk or a hike or a bike ride. I want to just lift some weights, so I’m going to add another day back to the gym.” And I fluctuate depending on the time of year and what’s going on. But I also think that there are people who are a little misguided. They think that the only way to achieve a certain look and feel in their bodies is through X number of hours [and] X number of days in the gym. The goal is to really show people, “Hey, that’s an unrealistic expectation for your lifestyle, and it’s not true.” We can do it [in] other ways. And we could probably find ways that are much more interesting and fun and engaging for you, based upon your personality type and what you like to do. You like to be outdoors, [and] you like to do sports. Why don’t we make that a central focus and then make training simply a complement to that to keep you being able to enjoy it as much as you want to enjoy it?
Chris Kresser: Yeah, that makes sense to me. And again, I really do appreciate that there are people [like that], and I was, at one time, [one of them]. I spent a lot of time in the gym, and that was great at that time. Some people just love that experience, like you’re saying. But for those who are in the gym because they think they have to be [there] for 12 hours in order to get the results, that’s what we’re addressing here.
Marcus Filly: Exactly.
Chris Kresser: And some people might be more motivated to go to the gym if they love tennis or skiing and they want to push that to the next level. Having that goal and using training as a way of not only meeting the basic needs like building muscle, or maintaining muscle mass at the very least, but also helping them achieve a different level of movement and attainment in something that they’re really interested in could help with motivation a lot.
Marcus Filly: Oh, yeah, certainly. Finding a way to connect what you’re doing in the gym to what the actual outcomes that you want in life are [is] central to this. Don’t just blindly go to the gym and follow a generic [prescription] that’s out there that might not even really apply to what you want. “You’ve got to go 90 minutes, five days a week.” No, you don’t. You don’t have to. Let’s look at a bunch of different ways that we can do this. I think what we were seeing toward [the] tail end of when I was coaching a lot of individuals in CrossFit was that there’s all this time and dedication to the gym, and I think it got way out of hand for a lot of people. They hit a wall, and they’re like, “What am I doing? Why am I spending so much time here?” That happens when people start doing anything without intention and thinking about the big picture [and] what they want out of it. They’re just following the herd.
Chris Kresser: Yeah, [that’s] often not a good strategy in life for anything, much less exercise. So, walk me through a typical workout. What that might look like in your approach, in terms of the types of exercises that are done [and the] rest periods. What does it actually look like?
Marcus Filly: I really believe firmly [that] the most important 10 minutes in the gym [is] how you start. The warm-ups that we coach people through put a lot of thought and intention into getting people to arrive into the gym space in a purposeful way. You’re transitioning from whatever you’re doing before the gym, to the gym. A lot of people [go to the gym] at the end of their workday, or even before they start their workday, [and] they [have] a bunch of things on their mind. So we always start with a 10-minute focused warm-up that gets blood flowing, gets [the] respiratory rate up, and works on stability or mobility-type movements. Things that are going to put some attention to your joints, joint health, and range of motion prior to training. I like to say [that] if you’re going to commit to one thing today, just go into your warm-up. By the end of your warm-up, you’ll probably want to do the next part. You’ll be ready.
Then we always have a strength training component. I bias toward a lot of timed strength training formats, like every minute, you’re going to do five back squats or you’re going to do 10 strict presses. And you do that for a certain number of minutes. Or maybe you superset that with another strength training exercise. A lot of the strength training that I write in our programs is about efficiency and keeping people focused when they’re in the gym. I think one of the challenges a lot of people face with weight training is that it’s less engaging [than] a bootcamp style or cardio class or something like that, where it’s like, “Hey, the clock’s going; I’ve got to keep going.” It brings some of those elements into weight training so that people feel like they’ve got time motivation. They’re not wasting minutes getting pulled into their phone on social media while they’re resting for their next set of bench presses, or whatever exercise they might be doing.
So [there’s] a big strength training component of each session, and for that, I like to stick to a lot of the traditional compound exercises. We have options for people at different levels of training. That [might] be power cleans for somebody, but it could be a split squat or weighted lunge [or] something [else so] that, for whatever skill level you’re at, you can give a lot of intensity and a lot of effort, but be working in a safe environment. Going back to the original CrossFit, what was so great [is that] it got people weight training, but in a class of 20 people, [only] four people could safely do power cleans at an intensity level that would make positive change in their body, [and] the other 16 were either having to do really, really light weights because they needed to work on technique and skill, or they were using weights that were too heavy for their technique and were at risk of injury. So how do we take the best of that and create the right environment so that somebody can come and lift weights, push against resistance hard enough to make change, but [the] skill is well within their wheelhouse and their repertoire, and they’re not going to get injured and be at risk? That’s always part two of training.
Chris Kresser: So Marcus, how long would that take? [There’s a] 10-minute warm-up, and then how long would that strength training component be?
Marcus Filly: Probably in the 15-minute range.
Chris Kresser: Okay, so it’s pretty concentrated.
Marcus Filly: Yeah, it’s concentrated, and this is also not going to be the only resistance training we do for the day. But this is the concentrated lifting of the day, where I want you to actually get close to failure. I want to push you to a place that feels a little uncomfortable with your weight training. That’s where we’re going to see change.
The next section of training is what a lot of people would think of as accessory weight training [or] accessory lifting. We like to call it strength-balanced training. This is where, rather than going to this set of split squats or single-leg [Romanian deadlifts] with the intention of [wanting] to push [yourself] as hard as [you] can, instead, I want you to think of this as your quality movement sets of the day. How can you extend your range of motion? How can you work on your coordination [and] your balance? How can we get into positions that enhance your mobility? I think that a common misconception is that weight training makes you get tighter and lose flexibility. That couldn’t be further from the truth. Proper resistance training is the best way to enhance range of motion and mobility. All the best protocols for getting you more flexible involve resistance. It could be isometric resistance, but it’s still resistance. [If you look at] the functional range conditioning people of the world, they’re expanding [the] range of motion in [their] joints through isometric contractions. Look at high-level gymnasts. When they are improving range of motion and flexibility for their sport, [they’re doing] tons of bodyweight resistance, compression drills, [and] extreme levels of isometric contractions, as well.
[The] same can be said for lifting weights. Ben Patrick, who’s the knees-over-toes guy [and has] gotten a lot of attention over the past couple of years, [is] using resistance training to expand joint range of motion tremendously. That’s how we approach this second tier of resistance training in our programs—[using] weight training to enhance range of motion, build better mobility [and] coordination, things like that. And that happens at submaximal weights. When you push maximally with weight training, your brain will purposefully close off [the] end [of your] range of motion because that’s where you’re at most risk of injury. But if I take 50 percent of my max and really focus on getting a deep stretch at the bottom of my squat or exploring a different position, that’s where you can see lots of change to the tissue quality and length. So there we are. One, two, three. That’s the third section. That’s another 15 minutes of training before we move into the final part of training, [which is] the functional conditioning stuff that most mimics what CrossFit introduced to my life [and] will stay with me forever, which is the concept of mixed-mobile conditioning, where you take weights, gymnastics, calisthenics, [and] cardio, and you put it all together in a circuit. We have hundreds of different formats that this looks like, but we’ll spend 15, maybe 20, minutes at the end of the training session including that [type] of conditioning.
Now, I [am biased] toward the aerobic spectrum of training. I tell people [that] aerobic training is sustainable training, [and] anaerobic training is unsustainable. With CrossFit, it was, “Go as hard and as fast as you can, [and] get the best time possible.” I’m saying [that] if you go 80 [to] 85 percent of that [and] you stay in much more control, you still work super hard, but you don’t have the thought in your brain of, “I’m going to die. I can’t do this anymore.” [Instead], you are thinking, “This is hard work, I’m doing well, I’m going to finish, and I’m going to end my training session.” And within five minutes of my training session being over, I have my wits about me and can walk out [of] the gym and not want to go take a nap for the rest of the day. So that’s how we construct our conditioning workouts. That’s just from years of practice, and trial and error. Knowing this works, that doesn’t work. If we do it this way, it’s going to push way too hard. If we put in this rest period or interval, or we inject this control point or scenario, [it’s] going to keep people safer [and] moving with better quality, [while still] keeping their aerobic system high. We educate people [on] how to do that.
So [those are the] four pillars of a good Functional Bodybuilding training session, the intention behind each one, and how I arrived at [them]. “Why are we doing that?” Well, because we want to keep people’s joints strong and healthy because [we] want to use the efficacy of lifting heavy weights, [and] because the conditioning lessons that I learned from CrossFit were so engaging and so efficacious for people when they learn how to not push to the red line. It all has gone into constructing this model that seems to work really well for a lot of people. We try [to] use a wide variety of [movements in there] because that’s what keeps people engaged and feeling like they’re learning constantly and not [feeling] like [they] do the same 10 exercises all the time.
Chris Kresser: That sounds amazing. I know a lot of people who listen to the show have a background in strength training, and they know how to do the basic movements. But they might not have someone [who] they’re working with on programming. One of the things I love about your work and your website is [that] there [are] lots of different entry points for people. There [are] eBooks on things like dealing with knee pain, functional body composition, conditioning, kettlebells, etc. You [also] have a membership program called Persist. Tell us a little bit about how that works.
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Marcus Filly: Well, you mentioned a few of the entry points for people to come into the Functional Bodybuilding universe. The Persist subscription was something that was born out of the pandemic and started in 2020, [when] most people didn’t have access to gyms. I created a training program that was built on the foundations of what we’ve been teaching for years, designed for people at home. So if you had a set of dumbbells, if you had a couple [of] resistance bands, [or even] if you [just] had your body weight, you could do Functional Bodybuilding in the way I just discussed. It became a place to bring our community together during a time of crisis. At that point, people weren’t buying eBooks to go to the gym because the gyms were closed. So, once we transitioned out of the severe lockdowns and gyms started to open around the world and around the country, we decided, “Okay, you know what? We’re going to take this central community, the Persist members, and reintroduce [them to] some of the other options for training.” We brought back [a] conventional gym or CrossFit-style gym equipment training program, where it’s like, “Hey, if you have access to this, this is how you can do Functional Bodybuilding.”
Then we added to that. It’s like,”Hey, if you want to do Functional Bodybuilding with more of an aesthetics focus on building muscle and really building your body composition, then [here’s] a new training track to offer.” And then a year later, it was, “Hey, if you have less than 60 minutes and you just need to get in and do the pillars of Functional Bodybuilding, we have an option for you within this subscription.” So Persist became a place where it’s like, “Hey, I want to be part of [the] Functional Bodybuilding ecosystem. I love what you’re about.” We’re going to deliver you a training option inside of [there] that will satisfy most of the buckets of what people are looking for. For our members, we offer training and a ton of free nutrition and lifestyle resources to help people pair optimal training with the things that will support that training for the other 23 hours of your day, most days of the week.
Chris Kresser: What would you recommend for someone who is relatively new to strength training? Maybe they don’t know how to do a proper squat or deadlift, they don’t have any history [with strength training], and maybe they don’t have access to that [type] of equipment. What would you recommend for them as a starting place?
Marcus Filly: When it comes to people [who] have very limited or no experience with training, it starts with just a willingness. Do you want to try? If you are open to learning and you’re patient, then learning how to go and move your body in functional ways is no different than learning how to roller skate or rollerblade. One day, you’re going to put on the rollerblades, you’re going to be wobbly, and you might fall over. But if you want to learn it and you see the value of it in your life, then [you’ve] got to give it a shot. An entry point for somebody like that with us might be the original Persist minimalist program, where it’s just with a dumbbell, or bodyweight, [or] maybe a couple of resistance bands, [and you] come and do the movements that we tell you to do each day. You’re going to learn how to squat, you’re going to learn how to lunge, [and] we’re going to ask you to do push-ups. If you have a pull-up bar at home, we might ask you to hang from a pull-up bar. Maybe you need to jump rope or run in place. But we’re not asking you to do an Olympic-style snatch in your program.
After you build a little consistency and prove to yourself that you want to learn this, then the ascension from there is easy. Now you’re going to grab the dumbbells. Now you’re going to grab a barbell. Are you ready for that? Do you want it? Okay, here’s a cheap way to buy a barbell and get it in your house, and we’re going to start teaching you how to do some squats. Nobody knows how to squat with a barbell on their back naturally. You’ve got to learn at some point, just like [you’ve] got to learn how to slap on the roller skates and get moving. We can do it in a very slow, gradual way. So Persist is still a place that we can funnel people in, but that initial question I ask [is], “Are you ready to learn? Do you want to learn?” Then you can navigate [from there]. If somebody’s like, “This needs to be so easy and just spoon fed to me,” then you’re probably best suited to find a personal trainer to work with. If you’re in that category of somebody who’s like, “I don’t trust myself to do this on my own,” [then] an online training program might not be the best place for you to start. Maybe you need to hire a personal coach. That could be somebody in person at your local fitness facility or [at] Functional Bodybuilding. We have seven FBB master coaches [who] consult with people online one-to-one. “Hey, Chris, let me write you a personal training program. We’re going to get on a call every two weeks [and] talk about it. I’m going to message you each day.” We have that level of service available in our company, if people are looking for that higher touch point to really get them going from zero to something.
Chris Kresser: Well, this has been a fascinating interview, Marcus. I’m really glad you were able to join me. I think people will get a ton out of this. Where can they learn more about Functional Bodybuilding and your work?
Marcus Filly: I encourage everybody to head over to Functional-Bodybuilding.com/free and get our newsletter. Get on our email list, where every week, I’m sending out [a message]. This week, we’re writing about bridging the gap from a high-stress period to getting back in the gym. “I was sick for a week. How do I get back into the gym?” Or, “My sleep has been disrupted for a month because we have a newborn. How do I get back into the gym?” Just giving people real, practical, useful tips and education every single week on training, nutrition, [and] lifestyle to keep living and breathing the Functional Bodybuilding lifestyle for years and years. So that’s a great place to start. And there [are] lots of free nutrition and training resources that you’ll get right away if you sign up.
Chris Kresser: Great. Well, thanks again, Marcus. [I] appreciate all the work you’ve done, and I encourage everybody to go check it out. [There are] lots of great resources there. And this approach to training just makes so much more sense to me, especially for the vast majority of people who are just trying to meet their goals of staying fit, building muscle mass, feeling good, increasing their performance in other activities, and avoiding injury. As I get older, that’s one of the number one goals that I have. I’m approaching 50, and I don’t recover quite as quickly as I did when I was 20 and 25. Whether I’m skiing, mountain biking, or lifting weights, that’s [always] in the back of my mind—wanting to do it in a way that is going to lower the risk of injury so I can keep doing it. Because I’m super impatient with being injured. I want to be able to get out there and do that every day. So I think this [type] of approach makes so much more sense for most people. So, thanks again for joining me and sharing your experience. And everybody, thanks for listening. Keep sending your questions to ChrisKresser.com/podcastquestion, and we’ll see you next time.
This episode of Revolution Health Radio is sponsored by Inside Tracker, Paleovalley, and Ava Jane’s Kitchen Colima Salt.
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Over the last many years, the Nutrition Diva podcast has discussed the effect of cholesterol on overall health many times. Today, we bring you some of the most impactful, data-based and diva-delivered information on the subject. We’ll touch on foods like coconut oil, oats, and eggs before wrapping things up with a lesson on how to raise your good cholesterol.
We kick things off with the Nutrition Diva discussing the impact – if any – that coconut oil has on cholesterol.
How does coconut oil affect cholesterol?
I have a good listener question for you this week.
Catherine writes:
I’ve lowered my saturated fat intake in an effort to reduce my cholesterol. Over the past several months, I’ve managed to bring it down about 40 points by reducing my red meat consumption.
I’ve also started to look for substitutes for full-fat dairy products like ice cream. Some of these, such as coconut milk based frozen desserts, have quite a bit of saturated fat. Is there a difference in the saturated fat of these two products in terms of how they affect my health?
As Catherine has discovered, reducing your saturated fat intake from food can be an effective way to reduce your blood cholesterol levels. Far more effective, in fact, than reducing your intake of dietary cholesterol. But saturated fats are a whole family of different fatty acids.
Here’s a quick review for those of you who might need a refresher on your fatty acid chemistry:
All fatty acids are “hydrocarbons,” meaning that they are built from carbon and hydrogen atoms. The carbon atoms form a sort of backbone, to which hydrogen atoms attach in various configurations.
When each of the carbons in the chain is linked to two hydrogen atoms, we say that it is fully hydrogenated, or saturated. (If some of the carbons have only one hydrogen partner, it’s an unsaturated fatty acid.)
Saturated fats come in a variety of lengths, though. Butyric acid is a stumpy little thing, only 4 carbons long. Butyric acid is found in butter. (Butyric/butter sound similar, which makes that easy to remember.) Stearic acid, on the other hand, is a rangy 18 carbons long. Meat is relatively rich in stearic acid. (You can remember this because stearic sounds like “steer.”) Lauric acid, found in coconut oil, is in the middle, with 12 carbons. (I’m afraid I don’t have a handy mnemonic device for that one.)
So the question is whether all saturated fats tend to increase blood cholesterol or only some of them. And, by extension, is butter better or worse for your cholesterol than beef or coconut oil? Or, as Catherine is wondering, would a frozen dessert high in coconut oil be better or worse than full-fat ice cream?
You would think that this question would have been settled by now. But there’s not as much research as you might expect—and the results are a bit mixed. The effects of different fatty acids on cholesterol levels vary, depending on the total amount of fat and saturated fat in your diet, as well as whether or not you have other risk factors for cardiovascular disease.
All the different types of saturated fats (including those in coconut oil) tend to increase total cholesterol levels, but there are some significant differences in their effects on HDL (the “good” cholesterol) and LDL (the “bad” kind).
So, here’s my best advice, based on the research I reviewed. If cholesterol is a concern, you are probably wise to limit your saturated fat intake (from all sources) to no more than 10% of calories. (For the typical adult, that’s about 20 to 25 grams per day.) Monounsaturated fats, such as those in olive oil and avocado, are really your best bet. (And here’s a fun fact: Most cuts of beef contain roughly equal amounts of monounsaturated and saturated fat.)
That’s not true of butter, which is mostly saturated. I really like the taste of butter, so I blend up a stick of butter with an equal amount of olive oil to make a “better butter” that is about half and half monounsaturated and saturated fat. As another plus, it’s spreadable straight out of the fridge, so it won’t tear up your toast.
But, back to Catherine’s original question: in terms of the effects on cardiovascular risk, a coconut-based frozen dessert would appear to be a better choice than full-fat ice cream. Both might have comparable amounts of saturated fat, but the saturated fatty acids in coconut oil are less likely to drive up LDL (“bad”) cholesterol.
However, if you’re trying to reduce your total cholesterol levels, you’d probably want to save the full-fat frozen desserts for special occasions—and in that case, I think you can afford to have whichever one tastes better to you.
Eggs and Oat Bran: The Cholesterol-Fiber Paradox
If cholesterol from food doesn’t affect blood cholesterol levels, why does eating soluble fiber reduce cholesterol? Nutrition Diva explains this apparent paradox.
A listener named Dan asked:
We’re told that eating foods like oatmeal, which contains soluble fiber, can help lower cholesterol. My understanding is that this works because the fiber binds to the cholesterol in your food, preventing its absorption.
But we’re also told that the amount of cholesterol in your food doesn’t make much difference because, if you get more in your diet, your body just produces less.
If the soluble fiber is reducing absorption of dietary cholesterol, but dietary cholesterol doesn’t matter, then why would that reduce your serum cholesterol?
This is a great question but one that requires a bit of a deep dive to answer. But if this is not the place for deep dives into nutrition nerd-dom, I don’t know where is!
How dietary cholesterol affects blood cholesterol
About 80% of the cholesterol that’s circulating through your body right now was manufactured in your body, not extracted from your food. Most of that de novo cholesterol production happens in the liver, but small amounts are also manufactured in the small intestine.
And Dan’s absolutely right: The liver will ramp its production of cholesterol up or down in response to your dietary intake. Take in more cholesterol through food and the liver will make less, and vice versa. (Cholesterol production in the small intestine is not affected by that feedback loop, however.)
To some extent, the amount of cholesterol that you absorb from food is genetically determined. Some people are “hyper-absorbers” and for them, the amount of cholesterol in their food may have a bigger impact on their blood cholesterol levels.
But for most people, dietary cholesterol intake doesn’t have a significant impact on total blood (serum) cholesterol levels. More to the point, cholesterol intake does not appear to impact the risk of heart disease. This is why we are no longer advised to limit our consumption of dietary cholesterol (unless, of course, you’re one of those hyper absorbers).
If you’re looking for a dietary culprit for high blood cholesterol levels, look to saturated fat and refined carbohydrates, not cholesterol. Eggs and shrimp, which are both high in cholesterol, are virtually carb-free and relatively low in saturated fat.
How soluble fiber affects blood cholesterol
According to the National Lipid Association:
“Soluble fiber can bind cholesterol in the intestine and remove it from the body. Eating 5 to 10 grams of soluble fiber a day can help lower total and LDL-cholesterol by 5 to 11 points, and sometimes more.”
You might imagine that when you eat eggs and oatmeal for breakfast, the soluble fiber in the oatmeal attaches to the cholesterol in the eggs and escorts it out of your body. And because you didn’t absorb the cholesterol from the eggs, the liver will compensate by making more, and the two effects will cancel each other out.
But the cholesterol that the fiber is binding to and removing from your body is not necessarily from foods that you eat. And this may explain the apparent paradox.
A lot of the cholesterol that your liver makes is used in the production of bile acid, which is released into the small intestine to help your body digest and absorb fat. In fact, your body converts about 500 mg of cholesterol a day to produce bile acids. That’s almost twice as much as most people take in through food, which is why the liver has the ability to produce more.
Most of the bile acids that are secreted into the small intestine get reabsorbed into the bloodstream as they pass through the ileum, which is the last stretch of small intestine that food goes through before entering the large intestine. At that point, the only things that get absorbed back into the body are water and electrolytes. Everything else gets eliminated as waste.
But soluble fiber binds to bile. So instead of those bile acids being reabsorbed and recycled, they are eliminated. That means the liver has to produce more bile to replace what is lost. Your liver then pulls more cholesterol out of your blood in order to make more bile acids—and that’s the primary mechanism by which soluble fiber reduces blood cholesterol levels.
Adding soluble fiber to your diet will have a bigger impact on your blood cholesterol than reducing the amount of cholesterol in your food. Studies show that this is true both for people with and without high cholesterol.
It’s also true for people who are also taking statin drugs because statins reduce cholesterol through a completely different mechanism. Cholesterol is produced via a long chain of biochemical reactions known as the mevalonate pathway. Statins block the very first reaction in this pathway, which effectively shuts down the rest of the pathway. This decreases the amount of cholesterol that the liver can produce, thereby lowering blood cholesterol levels.
The link between high cholesterol and heart disease
But does lowering blood cholesterol really reduce the risk of heart disease? Some research suggests that the link between high cholesterol and heart disease is not nearly as straightforward as we have been led to believe. Although high levels of cholesterol (especially LDL cholesterol) are associated with an increased risk of heart attack, the majority of heart attack victims have normal cholesterol. And while the use of statin drugs does appear to reduce mortality, there may be other factors at work. In addition to reducing cholesterol levels, for example, statins also reduce inflammation—which is another risk factor for heart disease.
The decision to prescribe a statin drug should ideally be based on more than just one’s LDL cholesterol levels. The amount, type, and ratios of other blood fats, age, sex, personal and familial health history and other risk factors should all be taken into consideration.
But whether or not your doctor feels that a cholesterol-lowering medication is right for you, eating soluble fiber offers a variety of benefits. In addition to lowering your cholesterol, they can also help modulate appetite and help with weight management, as well as promote the growth of beneficial bacteria in your gut. You can get soluble fiber in oatmeal and oat bran as well as apples, pears, plums, barley, chicory root, Jerusalem artichokes, mushrooms and garlic. Fiber supplements made from psyllium husk (Metamucil) or wheat dextrin (Benefiber) are also good sources.
How to Raise Your HDL
Having more HDL or “good” cholesterol in your blood reduces your risk of heart disease. Here are three ways to increase your good cholesterol level.
When people pay attention to their cholesterol levels, they’re usually focused on trying tolower them. But lower isn’t always better. Your total cholesterol level includes several different types of cholesterol.
What is HDL Cholesterol?
One type called high-density lipoproteins, or HDL, actually protects you against heart disease by carrying excess cholesterol back to your liver. That’s why you’ll often see it referred to as “good” cholesterol. In general, higher levels of HDL cholesterol are a good thing. And what you eat can help improve your HDL levels.
How to Raise Your HDL or Good Cholesterol
One way is to eat a diet high in sugar and refined carbohydrates. The only problem is that you’ll also end up increasing your LDL cholesterol and your triglycerides. Any benefit you might get from higher HDL is canceled out by increasing these other risk factors.
For this and lots of other reasons, I suggest you limit your intake of sugar and refined carbohydrates like white bread. You don’t have to go low carb. Just eat most of your carbohydrates in the form of fresh fruits and vegetables and whole grains.
How Fats Affect your Cholesterol Levels
The best advice I can give you is to avoid very low-fat diets.
The fat in your diet—both the type and the amount—has a big impact on your cholesterol levels but it’s tricky. Diets high in polyunsaturated fat, which is found in nuts, seeds, and vegetable oils, tend to lower both types of cholesterol, both HDL and LDL. Diets high in saturated fat, on the other hand, which is found in meat, dairy products, coconut and palm oils tend to raise both types of cholesterol—also a mixed bag.
The best advice I can give you is to avoid very low-fat diets because they don’t really move anything in the right direction. As far as your cholesterol profile goes, a diet that’s a little bit higher in fat is probably a better choice than one that’s high in carbohydrates. And there appears to be some advantages to including both saturated and unsaturated fats in your diet. In other words, there’s room for both peanut butter and cheese!
Whatever you do, however, continue to be vigilant about avoiding foods made with partially hydrogenated oils. These are the dreaded trans fats, of course, and among their many sins is a tendency to lower those good HDL cholesterol levels and raise the bad LDL levels.
Other Foods that Raise HDL Cholesterol
Foods that are high in soluble fiber, such as flax seed, apples, oranges, and soybeans may help boost your HDL levels. Having a glass of wine with dinner appears to help as well (see above).
Olive oil and fish are often cited as foods that help raise HDL levels. However the actual evidence on this is somewhat weak. But because olive oil and fish oil both have other well-documented benefits, particularly for heart health, I think it’s a great idea to include them in your diet anyway.
A Mediterranean Diet May Boost HDL Cholesterol
So, let’s review what we have so far:
Avoid refined carbohydrates and trans fats
Eat plenty of fruits and vegetables
Eat whole grains in moderation
Don’t avoid fat
Eat fish, nuts, olives, and seeds
Enjoy alcohol in moderation
If all of that sounds kind of familiar, you may be remembering my article on the Mediterranean Diet, which is essentially what I’ve just described. And, in fact, the Mediterranean Diet pattern has been found to raise HDL levels and otherwise positively affect risk factors for heart disease.
More on How to Increase HDL Cholesterol
Aside from diet, there are a few other things you can do to positively affect your HDL levels.
Be a woman. Women tend to have higher HDL cholesterol levels than men, especially before menopause. Of course recent advances in medical technology notwithstanding, there’s probably only so far you’re willing to go in order to boost your HDL levels. So, let’s focus on things that are a little easier for you to change.
Maintain a healthy weight. Higher body weights are associated with lower HDL levels, and vice versa. Being able to zip up that prom dress or tuxedo 20, 30, or even 40 years later is more than class reunion vanity—it’s a prescription for a long and healthy life. Quick tip: If you are actively losing weight, you may see your HDL levels decline but once you stabilize at your goal weight, your HDL should rebound to a higher, healthier, level.
Work out. Engaging in moderate to high intensity aerobic exercise will raise your HDL levels, especially if they’re on the low side. If you need help getting motivated, look no further thanGet Fit Guy’s Quick and Dirty Tips to Slim Down and Shape Up.
Live a Healthy Lifestyle and Don’t Worry
Honestly, if you want to know how to increase HDL, the best way to get healthy levels is just to eat right and get some exercise. When you live a healthy lifestyle, HDL levels tend to take care of themselves.
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