Cholesterol, Culture, and Being Flexible!

The South Asian Health SolutionThis is a guest post from Dr. Ronesh Sinha (aka Dr. Ron). Dr. Ron is an internal medicine physician in Northern California. He specializes in helping patients from diverse ethnic backgrounds reduce heart disease risk factors through lifestyle changes. I’ve recently published Dr. Ron’s book The South Asian Health Solution. You can learn all about the book and the special offer that ends tomorrow here. Enter Dr. Ron…

I started off about a decade ago with an internal medicine practice in the heart of Silicon Valley. I learned from medical training that a typical heart attack patient is an overweight, old white guy who smokes and eats red meat. That would have been incredibly useful if I was put in a time capsule and sent back to the 1950s to practice medicine in the heart of Framingham, Massachusetts, which is where the outdated guidelines originate from. I was flooded with sedentary, mostly non-smoking, non-white, non-obese and often vegetarian patients who looked nothing like those case studies from medical training. Back then they were getting employer-based health screenings that only drew their total cholesterol level. Most of them had a total cholesterol of less than 200 and if these screenings happened to check LDL levels they often looked “good” also. These individuals were patted on their back, told they were doing great, and sent home. However, these same patients, mostly Asian Indian, were developing rampant diabetes and heart disease. One of my first heart attack cases was a 32-year-old, non-smoking Indian vegetarian. I started seeing similar cases and as I delved through the research back in those early days, I discovered that Asian Indians had one of the highest incidences of heart disease in the world. The part that puzzled me was when I looked at their cholesterol through my medically trained Framingham lens, their cholesterol numbers continued to look pretty normal…or so I thought! I went to big companies and lectured about cholesterol and feverishly preached the virtues of a low-fat, high fiber diet, one that I also practiced. However, something started happening. I never reached an overweight BMI, but my waistline did start expanding a bit and as I started checking my own numbers I noticed that my total cholesterol and LDL looked really “good,” but the other numbers on my cholesterol panel didn’t. Let’s take a look at my lipid timeline:


Look at my numbers from 7/2009. Total cholesterol of 154 mg/dL and an LDL cholesterol of 85 mg/dL. These are numbers that would make most conventionally trained physicians proud. Unfortunately, the majority of physicians ignore a far more important number, the Triglyceride-to-HDL (TG/HDL) ratio, a marker for insulin resistance, which you can see was a whopping 11.2 back then. I had developed metabolic syndrome, the dreaded insulin resistant condition that significantly increases heart attack and stroke risk. The goal is to get the TG/HDL ratio below 3.0 and the lower the better. I did do an LDL size profile as you can see from the results and it showed that I was carrying the more ominous, small dense pattern B LDL. Not necessarily ominous because of its size, but because pattern B is usually (not always) associated with greater LDL particle numbers, the real lipid risk marker for atherosclerotic plaque.

Now, as I transitioned to a more ancestrally-aligned lifestyle thanks to Mark’s Daily Apple, notice how my good cholesterol (HDL) goes up 19 points to 47, my triglycerides drop to 74 and my ratio drops to 1.6. To achieve this type of progress from the knowledge I gained from medical training I’d be taking enough of the prescription drug Niacin to make me flush and possibly raise my blood glucose, while throwing down a ton of fish oil capsules and still my results would not be as impressive. However, Dr. Framingham (not an actual doctor, but one who rigidly adheres to Framingham dogma) would cast a disapproving stare, pointing out that my total cholesterol went up 30 points to 184 and that the all-important LDL jumped 37 points. Surely that was due to all those artery-clogging egg yolks I was eating, right? Stop the eggs and here’s some Lipitor! However, notice that my LDL particle size transitioned to type A and if I had checked my LDL particle numbers back then, they would have gone down. If I’ve lost you on any of this, I use illustrations and my “6 Cholesterol Rules” in the cholesterol chapter of The South Asian Health Solution so patients and doctors clearly understand how to interpret lipid panels and when to order advanced lipid tests. In an ideal world all doctors would replace the currently outdated lipid test with an advanced test like the NMR LipoProfile, but it is still possible to make some pretty accurate risk assessments when you follow my cholesterol rules. If doctors wonder if this information is up to date, I also incorporate the 2013 cholesterol guidelines which in many ways actually supports this approach. I did a blog post on the new guidelines here. Just remember that in most cases when you reverse insulin resistance by improving your TG/HDL ratio your total cholesterol may go up thanks to a rise in your healthy HDL cholesterol and your LDL may go up too thanks to a shift from LDL subtype B to A, which means you have fewer large particles carrying more cholesterol. This phenomenon commonly elevates the LDL level on a standard lipid panel (aka “LDL-C”). I actually tell my patients and referring doctors in advance to expect a “healthy rise” in these numbers as we reduce their risk and improve their overall health. By the way, the good news is I have several doctors who refer patients to me and they are understanding and fully endorsing this approach after watching their patients reverse insulin resistance, shed excess body fat and often get off their drugs. I work in a group of over a thousand doctors and I also work with major health insurance plans who are starting to acknowledge that the current regimented, government-endorsed guidelines are failing miserably. I even have a growing panel of physicians, among whom obesity and insulin resistance are becoming a major problem, who have now become my patients since the very system they are working in is failing to give them effective risk-reducing lifestyle solutions. There’s a ton of work left to do, but I’m happy to see that there is a groundswell taking place within the medical community.

Now I want to make an important point here. I discussed how Dr. Framingham and my past self overly prescribed to regimented, outdated guidelines. When I made the transition to my current lifestyle I must admit that even my prescription of ancestral practices was initially over regimented. Although this was effective for some patients, for others it created more stress. As much as people say this way of eating is “easy,” it ain’t that easy for individuals like vegetarian Indians who come from cultures where legumes, flatbreads and rice are core staples. We also have to be careful using words like “safe starch” for rice. Yes, rice in moderation and timed appropriately can be a “safe starch” for someone who is or becomes insulin sensitive and metabolically flexible, but not for someone who is highly insulin resistant. I recently had a Chinese Google engineer come see me with advanced metabolic syndrome, telling me after his highly selective online research that he is continuing to pound large amounts of rice since it’s considered “safe.” I told him it’s not safe now, but we may be able to make it safe if he follows my plan.

Fortunately, plenty of my vegetarian Indians have been able to hang onto some of their legumes and controlled portions of rice and do just fine. I thank Mark and the Primal Blueprint Publishing team for allowing me to include this vital information in my book for vegetarians so they don’t feel excluded from this potentially life-saving approach due to rigid rules. Mark has been at the forefront of making this movement inclusive and flexible so all people can benefit, regardless of their level of motivation, instead of adopting an extreme mantra like “ditch the grains or die!” Forcing individuals to completely eliminate foods they consider integral to their culture only increases stress and possibly inflammation like this guy:


Notice how when his TG/HDL ratio was “optimal” in July 2013 at 1.8, his hsCRP was 3.6, slightly above the upper limit of 3.0. Yes he was satisfied, but not completely happy with his initial eating plan so I let him add back in some more legumes and rice. Unlike the Chinese Google engineer, this patient earned back his metabolic right to have some of these grains after he achieved insulin sensitivity through ancestral-aligned lifestyle changes. His TG/HDL ratio did go up a bit in October to 3.1, but notice how his hsCRP, a blood test marker for inflammation, dropped to an optimal level of 0.6. The hsCRP is a part of the “Metabolic 6-pack” tests I discuss in the book, which is a modification of the metabolic syndrome criteria. So this patient had a lower inflammation (hsCRP) despite his TG/HDL ratio being a touch higher, and as most of you already know, inflammation is the real underlying culprit for heart disease, chronic disease and premature aging. I see this pattern frequently enough to assume that making a diet too restrictive to adhere to rigid guidelines may be doing more harm than good. It’s not always elicited by checking a simple blood test like the hsCRP. Often you need to sit back and ask yourself if this way of living is making you happy? If the answer is a resounding no, you need to re-evaluate your choices and loosen the reins a bit. I initially may have gone from being “Dr. Rigid Framingham” to “Dr. Rigid Paleo,” but am now backing off if I sense that patients are persistently overwhelmed by my prescribed lifestyle plan. If you are killing yourself trying to achieve single digit body fat or a personal best in some endurance event, or if living in ketosis is not truly effortless due to other life obstacles or cultural constraints, you may need to back off and find a path that works and feels better for you. Stress and sleep trump everything and I focus on these in detail in my book, including devices and apps pulled from my TED talk and corporate wellness programs that have really helped struggling individuals achieve better life balance. Mark wrote up in a recent post that studies show the best exercise is the one you enjoy. This same philosophy can be applied to your diet and overall lifestyle plan. Fortunately there are a plethora of options with this style of living that can allow you to optimize health while maximizing enjoyment.

I want to end by saying thank you to Mark and the Primal team for publishing this book, and to the whole MDA community who helped guide me towards the right answers and have also served as a support community for my patients.

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54 thoughts on “Cholesterol, Culture, and Being Flexible!”

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  1. Just so I’m clear, the vegetarian Indians are able to make these beneficial changes to their diet and still remain vegetarians, right?

    1. Mark’s healthy, 18 y.o. son is (last I heard) a 100% life-long vegetarian. You can do vegetarian Primal/Paleo. (FYI, I am not vegetarian.)

      1. An 18 year old would be too young to be described as a “life-long” anything.

    2. should be fairly obvious…they can cut out the processed snack crisps fried in vegetable oils and use ghee/butter to cook instead of vegetable oils…cut out the naans and rotli and stick to lentils and rice for carbs. Increase vegetable consumption and decrease the horrible sugar treats…how could that not benefit

    3. I would say that depends on your definition of vegetarian. Include eggs and cheese regularly and you’ll probably be fine. If you can’t eat eggs for some reason? Probably not.

      1. Can still make it work and really depends on the individual and their level of insulin sensitivity. If they’re insulin resistant, dialing up activity and adding weight trainig is critical to compensate for the extra carbs.

        1. I was thinking more of nutrition rather than insulin sensitivity. Eggs have so many good things. 🙂

      2. I believe eggs are not acceptable for many Hindus. It depends on how religious you are and if you are vegetarian for religious reasons at all, I suppose. I’m sure not every vegetarian Indian is Hindu, but I’d imagine that it accounts for the majority of the vegetarian Indian trend that Dr. Ron describes.

    4. I just wondered if this book actually is about being paleovegetarian. I know that in general paleovegetarianism can work.

    5. Yes, absolutely. If I can get them to hold onto eggs and dairy it’s a huge win, but I’ve made it work even without.

  2. Hubby and I aren’t Asian, but we’re about to embark on our own N=1 experiment using beans on a weekly Carb Nite Solution regimen, meaning something with beans every Friday night for a month. I’ll start with chili.

    We already did an experiment on so-called “resistant” rice, and it works best when applied in a once-weekly dinnertime feeding for him. Bananas and potato starch? Forget it! Saturday night potato salad (made with red potatoes) he can do, and it does work as promised. We will be putting the potato salads on hold during the bean trials.

  3. This kind of information is really helpful. We need to be able to understand the test results so we can make some informed decisions, rather than passively accepting whatever the doctor tells us. It needs to be a partnership between the doctor and the patient, in which the doctor doesn’t patronize the patient and the patient acts more proactively to understand the medical science.

  4. I moved recently to the Portland area and am struggling to find a PCP who is supportive of this lifestyle. In this article, Dr. Ron mentions that he works with ” a group of over a thousand doctors,” and I wonder if anyone knows if there is a website or network somewhere that would help me to locate some of these doctors.

    1. I would really like to find a PCP that believes in the Primal lifestyle and supports this view of cholesterol and risk factors also. I live in San Diego.

        1. I found a good doctor in Denver this network. Cross-referenced with my insurance provider and bingo!

        2. Thanks for this – I thought PPN was just a US thing, but I not only found a doctor in Wales but in my nearest city!

      1. If looking for PCP, I recommend the black market or a horse veterinarian.

      2. I know this can be a challenge. I put a section at the end of every chapter “for professionals” to help educate our docs on these issues and am going on an MD tour to spread the word. You may not be able to find a primal doc”in your area but one with an open mind who is letting you try your n=1 is usually possible. Keep in mind that you can also order your own labs without a docs order online if you’re not able to get the data you want (labtestsonline or directlabs).

    2. Lindsay, Google Dr. Laura Torgerson. (Unless you meant Portland, Maine, in which case…sorry!)

      1. I work with Dr. Torgerson and she is great – I use her for my kid. She is a naturopath, though. Another good Paleo-oriented physician in Portland is Dr. Greg Nigh, also an ND. He is at Nature Cures Clinic.

  5. Great article! Definitely learnt from that post, and will definitely be looking out for more from Dr. Ron from now on!

  6. Speaking of eggs and cholesterol, I would be interested to hear if anyone has good data on how being a hyper-absorber (sometimes called hyper-responder) of dietary cholesterol affects LDL particle count. When I added eggs, both my HDL and LDL went up proportionally, just as I had read that they would, but treating that as benign seems like a pre-particle count view of the world. Hopefully it is benign, but I would be curious if anyone has up to date info on that. I have not been able to find a particle count-specific answer anywhere.

  7. Lindsay, Portland Where? They are both up. If you are talking “Moscow on the Willamette” or Portland Oregon, I may be able to help.

      1. Dr. Deborah McKay

        She is not really PCP, but, she is really really good. She is a Naturopath but,,, she won’t have you standing on your head with a glass of milk at arms length to see if your allergic type of Naturopath. She is aware of MDA, don’t know if she reads it as she is very busy.
        I know that she is covered by Blue Cross Blue Shield, my insurance does not recognize her. So I do the concierge thing and pay out of pocket. And it is well worth it, best doctor I have ever been to. Have an appointment with her at the end of the month.
        NOTE: She has a month lead time just to get into see her.

  8. Great post. This really resonates because I just had my lipid panel done after two years low carb (not fully primal yet but working in that direction) and, like a lot of people, I was a little nervous that my cholesterol would not show a positive change (it’s hard to let go of the conventional wisdom I have spent 40+ years listening to).

    I was pleasantly surprised to see my overall cholesterol drop with a healthy rise in my good cholesterol. But the real change was in my triglycerides– they dropped almost 100 points! I knew I felt better but seeing it backed up with actual lab results was thrilling.

  9. I’m really interested in this book. My husband’s Indian. When we go visit his family in India, we spend the whole time feeling somewhat sick. Maybe following the guidelines in this book will help us feel better during our trip & share with them some of the points about our way of eating that they might adopt for themselves.

  10. I was a vegetarian, but I only saw my health change for the better after I introduced fish into my diet. I also consume gelatin in tea.

    I don’t consider myself paleo/primal, since I don’t eat animal protein – I also eat a lot of lentils and rice (primarily idlis from fermented rice/lentil batter). What I’ve noticed is that as I get healthier, I’m also more carb-sensitive; eating a lot of carbs at night winds me up as much as a couple of cups of coffee. Maybe this is my body’s way of weaning me off the carbs?

    Also, any recommendations for a Primal/Paleo PCP in the Bay Area? I looked up Dr. Sinha, but he’s not accepting new patients 🙁

    1. I know this is OT, but can someone explain the “fish isn’t meat” thing to me? I’ve known others to say the same thing as primalnoob, but have never understood it, especially as I’ve caught a cleaned my fair share. Is it just a division between warm and cold blooded animals?

      on topic- this is interesting to see a different perspective on ancestral principles. I’m really just starting my lifestyle changes, so am really appreciating the openness of MDA.

      1. I can’t speak from a scientific standpoint, but, as a member of the Orthodox Church, whose fasting rules make a distinction (well, several, actually) between “fish” and “meat,” I would say that yes, it is a division between warm- and cold-blooded animals. Any tissue from red blooded animals is “meat”: beef, pork, lamb, goat, chicken, turkey, and so on. (There is also a category for the secondary products, such as eggs or dairy – bovine, ovine, caprine, equine, and so on – derived from red-blooded animals; even gelatine produced from the hooves of such animals.) Fish and other cold blooded animals, such as frogs and snakes, fall into a separate category; and finally, there is a category made of of animals that lack circulatory systems in a “formal” sense, such as shrimp, crabs, mollusks, and, yes, even insects. These rules go back many, many centuries, and there is a lot of reasoning (and some rationalizing) behind them from a faith-based standpoint; but at least we’d say your definition of the division has a long history of support!

      2. I don’t really differentiate between fish and meat from a dogmatic POV – I don’t eat animal protein because I can’t handle the texture (believe me, I’ve tried). Salmon slips down with tolerable ease, as does any other white fish suitably curried and well-cooked in coconut oil.

      3. From a taxonomic standpoint, fish, mollusks, and crustaceans are all animals and are therefore all meat. From certain religious perspectives, fish is permitted during times of fasting, even when meat is to be avoided. From an ethical standpoint, if someone is a vegetarian/vegan because they object to the killing of animals then they are probably fooling themselves if they eat seafood. From a dietary standpoint, seafood is meat, but is considered healthier by many because of the amount and type of fat.

        From my own perspective, seafood is healthy and delicious and I would totally eat more of it if I lived on a coast. I eat canned fish regularly, and other fresh or frozen seafood when it is high quality and reasonably priced, but those are two things that rarely go together. But I feel the same way about beef, pork, lamb, venison, etc. – healthy and delicious and best purchased when the quality is high and the price is low.

  11. 1. “Ancestral” eating for many South Indians would not include meat. I’m glad he recgonizes that when treating.

    2. The bigget problem for Indians who COME to this country (as oppposed to those who are raised here) is cooking is hard with new ingredients, and they all overdose on potatoes. Very hard to make veggie dishes when the veggies are so different.

    3. Eggs are easy to introduce, but if you are lifelong vegetarian the texture and taste is quite bad. Overcook them with onions and chilies into patties. Not tasty but you can put them down easier.

    I’d be curious to know more on his views on Vitamin D.

    The lack of exercise is really the biggest factor. At best a little cardio. Almost not weights or explosive movements.

    1. “1. “Ancestral” eating for many South Indians would not include meat.”

      Yes it would, vegetarianism is comparatively recent to India. Yes there have been vegetarians in India for many many years and it is traditional in that people’s grandmothers and great great grandmothers did it, but if you go back further people ate meat. Humans are naturally omnivorous and vegetarianism has arisen partly through spiritual ideals and partly through lack of availability (though this kind of “vegetarianism” would include meat when available).

      Interesting note – a major reason why Hinduism started to take vegetarianism as an important concept (it didn’t previously – even looking in the Ramayana and Mahabharata there are references to meat eating and many prominent ancient sages ate meat) is because of Buddhism and Jainism which really focused on the concept of ahimsa (non violence). Hinduism embraced this because it was a popular idea at the time. However, Buddhism does not especially call for vegetarianism (though many modern especially western Buddhists do) and the Buddha himself didn’t think being “picky” about food was a useful way to spend ones time.

      1. “Buddhism and Jainism which really focused on the concept of ahimsa (non violence). ”

        Yeah, so about 2000 years of being vegetarian.

        What is interesting that in living memory during the famines of the 40s people would bring wheat into villages, and people would rather die of starvation that eat it.

        50-60 years later chapattis are everywhere

        Genetic turnover happens really quickly. Those would could tolerate wheat lived. Those who didn’t died.

        1. Having traveled in Nepal and lived with a Hindu family of modest means I can say they are definitely not 100% vegetarian. Much of the time they are but they ate fish from time to time. I don’t think there is any evidence that Hindus have been strict vegetarians for 2000 years. And anyway, Hindus comprise a large and diverse population. I think if you look more closely you’d find class/caste has a lot to do with it. The higher castes eat more meat and animal protein in general and have always done so I would bet. It is really an economic issue as much as anything else.

  12. I write about the primal lifestyle living in India and I get so many emails asking about being vegetarian and still being interested in the primal lifestyle. I will point them in the direction of your book!

    1. Aloka, I’m so glad you posted! My husband and I are relocating from California to New Delhi soon. I’ve been moving us in the primal direction for the last year so I was wondering how that would transfer to our new location. I’m looking forward to reading your blog 🙂

    2. Thanks Aloka and great to seeing you doing this important work in the carb-driven battlefields of Mumbai.

      1. Thanks! It’s quite amazing to see the amount of interest there is in this lifestyle off late! I get so many people in Mumbai reaching out to me as they’re interested in learning more.

  13. Thank you for this great post, Dr. Sinha. I like the realistic and respectful approach that you take towards treating your vegetarian patients. Being South Asian, I can well imagine the obstacles that you face in persuading people to change their lifestyles. Insulin resistance, diabetes and heart disease are frighteningly common in my large circle of Indian friends. It’s no surprise given how high most South Asian diets are in carbohydrates. I can’t wait to read your book, and recommend it to people who need to get healthy.

  14. Fantastic article. Can’t wait to read the book. Thank you so much Dr. Sinha.

  15. Health insurance won’t generally covers GP services, long term diseases like diabetes, accidents or emergency incidents.

  16. Love this article! While my husband is not Indian, he is Persian, and similarly, traditional diet consists of rice, various flat breads and lentils, meat, etc. I started the paleo journey before he did, and thought it was “so easy.” However, for my husband, it was not so easy at all as Dr. Sinha mentions is often the case for people’s whose diets are rooted in tradition.

    Over time, I embraced a less dogmatic form of paleo that includes rice, legumes [check out Chris Kresser’s post on them… very informative! And I feel safe adding them back into my diet.], and occasional breads albeit gluten free. Is it paleo perfection? No. But it’s what works for us and I still feel great. It’s also something that my husband can adhere to much easier now and embrace paleo while still being true to his roots. We both lift heavy 4x a week, and just time rice, lentils, etc. around those days. “Off” days we’ll stick to low-carb, high fat.

    I once read on another paleo blog and unfortunately can not remember where, but really resonated with me, that when it comes to carbs, the idea is not to HAVE to be low carb, but to be ACTIVE ENOUGH that you NEED carbs to support your activity. Lifting takes care of that for us and now we can happily eat rice still when timed accordingly 🙂

  17. A particular section of this article caught my attention as I just had my physical exam this week and saw results from a blood work-up. Comparing my TG/HDL ratios from pre-primal (1.72) to two post-paleo ratios (.72 and .69), I’m on the right track, I would say…

  18. Been on Keto since 2015
    I just got my blood test today: (I fasted) it reads: March 2017 Cholesterol: 284 (ref range: none) HDL: 47 (ref range: >40 mg/dL) LDL, Calc: 208 (ref range: <100 mg/dL) Triglycerides: 112 (ref range: <150 mg/dL) Testosterone1109, (ref range: <193-740 mg/dL) Glucose (fasting): 94 (ref range: 65-99 mg/dL) The rest is normal… should I be worried about my liver? or how my cholesterol and glucose have increased a lot in the last months? December 2016 Total cholesterol: 258 HDL: 51 LDL: 182 Triglycerides: 98 Glucose 72 (fasting) Testosterone 766