Cholesterol, you poor, poor, misunderstood victim, you.
Cholesterol has long been quite the culprit when talking about heart disease risk. Considering heart disease affects about 85.6 million Americans and is a LEADING cause of death in the United States (1), this gives many reasons why we need to address the possible correlation. It is also a major financial burden, costing $320 billion annually according to the American Heart Association. So of course, OF COURSE, we want to work to prevent or decrease risk factors for this awful condition, right? Well, if high cholesterol is positively correlated with higher rates of heart disease, we can make decreasing cholesterol a focus and therefore decrease a risk factor, right? Perfect. Statins can do just that. Or if we decrease our dietary intake of cholesterol and saturated fat, we will decrease it too, right?
Well, is cholesterol really the issue, or is it just in the wrong place at the wrong time? Guilty by association? Are those drugs actually helping or causing a slew of other problems in the process? In this article, I will give you a breakdown of why we believe cholesterol is the culprit in heart disease and the related diet-heart hypothesis, what cholesterol is, how it is vital for life, and what you can do to lower your cholesterol without drugs.
What is the diet-heart hypothesis?
The diet-heart hypothesis has been the main driver of our fear of cholesterol. The hypothesis says that eating cholesterol and saturated fat raises cholesterol in our blood, which leads to atherosclerotic plaques that can develop into clots that result in heart attacks or strokes. Supportive research for this hypothesis is outdated and honestly not so sound to begin with. For example, there is research that involved feeding rabbits, animals that do not eat cholesterol otherwise, oxidized cholesterol and saturated fat (9). The rabbits then developed atherosclerosis (7,8), though it was not even the same type of pathology as human atherosclerosis (8)! Then the lovely Ancel Keys did his population-based dietary investigations and manipulated his research findings to promote the benefits of a low-fat diet. The shift in recommendations to low fat caused many to replace it with a higher intake of refined carbohydrates, vegetable oils and processed fats that are now at the root of SO many health problems. The major one being-wait for it-heart disease.
It doesn’t take a rocket scientist to understand the flawed nature of the research behind the guidelines, but unfortunately, we are now decades down the line and still practicing treatment protocols that decrease cholesterol without fully understanding the repercussions of such modalities, OR the alternative treatments. In fact, “The low-fat-high-carbohydrate diet, promulgated vigorously by the National Cholesterol Education Program, National Institutes of Health, and American Heart Association since the Lipid Research Clinics-Primary Prevention Program in 1984, and earlier by the U.S. Department of Agriculture food pyramid, may well have played an unintended role in the current epidemics of obesity, lipid abnormalities, type II diabetes, and metabolic syndromes” (9). Even with the growing amount of data showing that most heart attacks are actually occurring in people with low cholesterol (7), that the benefits of statins don’t relate to decreasing cholesterol but more so in decreasing inflammation (4, 7), that studies of low-carb diets with higher saturated fat intake resulted in improved cardiovascular risk factors like improved blood markers and weight loss (4), we STILL have a stubbornness to the protocol. Even if we see the benefit of decreasing inflammation with statins, there is a much healthier way to do so with simple lifestyle, supplement, and diet modifications (see my blog on inflammation!).
Either way, we do know there is a positive correlation with cholesterol and heart disease. We just need to understand WHY cholesterol is kicking it in the quantities it is in the blood stream and what may really be causing the potentially fatal atherosclerosis.
What is Cholesterol?
To put it plainly, cholesterol is a soft, waxy substance in your bloodstream and EVERY CELL in your body. It plays a vital role in your health, with many functions ranging from production of cell membranes, hormones, vitamin D, and bile acids to formation of memories and neurological functions (4). It is SO important, especially for proper development.
Did you know doctors are now prescribing statins to children as young as EIGHT years old?? (8) Kids NEED cholesterol for proper learning and neurological development. We all NEED cholesterol. But…how much?
When you go to the doctor and they tell you your cholesterol is high, low, or within range, what are they referring to? That assessment is based off blood lab values. You’ve got your HDL-High-density lipo-protein- (the “good” cholesterol they may say), your LDL-low-density-lipoprotein- (the “bad”), your triglycerides, and your total cholesterol. Cholesterol is insoluble in water, and needs transported in the plasma by lipoprotein particles. These proteins are characterized by size, density, relative content of cholesterol, triglycerides, and a few other things (6). The various types include chylomicrons, very-low-density lipoproteins (VLDL), intermediate-density lipoproteins (IDL), low-density lipoproteins (LDL), and high-density lipoproteins (HDL). With that said, these lipid markers are not the greatest for assessing cardiac disease risk. They do tell us how much cholesterol is in the lipid proteins, but the issue is a bit more complicated than that.
What is driving these numbers up or down? Is it LDL and triglycerides we need to worry about or do we know a more specific culprit in the cardiac risk game? I will get into this a little later, so for now let’s break down the various blood markers a little bit to get a better understanding of their functions.
- HDL: Takes cholesterol from your
tissues and arteries and brings it back to your liver. It is synthesized and
secreted by the liver and small intestine, traveling in the circulation where
it grabs up the cholesterol and returns it to the liver (3).
- Current Recommendations: 60 mg/dL or higher = good; 40-59 mg/dL is borderline; <40 mg/dL is low
- LDL: Delivers cholesterol to cells
where it is used in membranes or for steroid hormone synthesis.
- Current Recommendations: <100 mg/dL Optimal; <70 Optimal for those with known disease; 100-129 obove optimal; 130-159 borderline high; 160-189 high; >190 Very high
- Triglycerides: provide energy, stored in fat
cells. High triglycerides usually accompany other risk factors like high blood
pressure, high blood sugar, low HDL cholesterol, and abdominal obesity- all
part of the metabolic syndrome, which is a large risk factor for heart disease
and type II diabetes. High triglycerides by themselves may not be the most
concerning factor, but considering the others and other possible perpetrators
for the high triglycerides (like quality of your diet, lifestyle, etc.) should
be a main focus in treatment.
- Current Recommendations: <150 Normal; 150-199 Mildly High; 200-499 High; >500 Very high
- Total Cholesterol: LDL + HDL + (triglycerides/5) = TC
- This number is not a great identifier for assessing cholesterol, as it does not differentiate between LDL and HDL. We are also assuming we NEED to look at HDL and LDL when, as I mentioned before, the more important part of the story lies elsewhere.
- Current Recommendations:< 200 mg/dL; 201-240 mg/dL is borderline; >240 mg/dL is high
- HDL/TC ratio– Slightly stronger indicator of heart disease risk. Higher ratios correspond with higher risks. You want this to be under 25% (5).
- Apoprotein B. This is a protein in LDL particles. ApoB is reliable and accurate for measuring LDL particle count since every LDL particle has one ApoB. This is not normally tested in a basic panel, but should be requested.
Lets talk about LDL…
LDL particles come in many sizes. They not only carry cholesterol, but fat-soluble vitamins, antioxidants and triglycerides (10). With all of these taxi services, sometimes the LDL has a limit with how much of one thing it can take. Each LDL particle has a certain number of cholesterol molecules, and a certain number of triglycerides (10). They work inversely- the more triglycerides, the less cholesterol carried. When this happens, the liver has to make more LDL particles to compensate. So you could have two people with the same level of LDL- 120 mg/dL, but one of them has high triglycerides. The one with the higher triglycerides will have more particles. The high particle number has been associated with metabolic syndrome in quite a few studies involving 1,400-300,00 people (10).
Though the number of particles is the primary concern, there is special attention to small, dense LDL particle numbers. Sometimes the receptors of LDL particles get down-regulated, allowing them to spend more time in circulation and thus accumulating in the blood (5). The longer they hang out, the more time their fragile polyunsaturated fatty membranes spend around oxidative forces like inflammation, and thus get broken down eventually, leading to oxidation of the LDL particles (5). They then can be problematic because they can squeeze through the lining of the arteries and form atherosclerotic plaque (5, 10). So, we not only want to look at total particle number, but knowing the size can also help us determine what may be the root issue.
How and why do things get so out of whack?
The body has a range between 1,100 and 1,700 milligrams of cholesterol in our bodies (5) on any given day. We are VERY good at regulating blood cholesterol levels on our own. About 75% is produced by our liver, and about 25% comes from our diet. If we eat more, we make less, and vis versa. The liver secretes excess cholesterol in bile or converts it to bile salts. So, what happens when things go wrong?
Possible Causes of High Cholesterol:
- Dysfunctional thyroid. If hypothyroid problem, cholesterol can rise. Your thyroid also needs some carbohydrates, so sometimes people see a rise in cholesterol when they switch to radically low carb/keto diets. We can also see a rise with PCOS, pregnancy, and menopause (6).
- Rapid Weight Loss. As your body starts losing fat, it may get built up more in the blood stream, causing the lab values to be elevated.
- Diet and Lifestyle
-sugar and refined carbohydrates
-eating foods cooked at high temperatures
- Genetics: There is a condition called Familial hypercholesterolemia (FH) that is an autosomal dominant disorder that, depending on the homozygous (1 in 500) or heterozygous (1 in a million) mutations, have varying prevalence. Basically, it involves a mutation of a gene that codes for the LDL receptor sites on the outside of cells (10). There is an inability to clear LDL from plasma in a timely manner and therefore has too much build up in their blood. People with the homozygous mutation have extremely high cholesterol levels, sometimes as high as 1000 mg/dL (10). The heterozygous carriers have total cholesterol that range 350-550 mg/dL, along with ver high LDL particle numbers. Their risk of heart disease mortality is about three times more than those without FH if it goes untreated. This condition requires more rigid dietary interventions to prevent the build-up.
- *A note on genetics*– I get people that come in and say that high cholesterol runs in their family. This is RARELY due to FH and is more often due to family eating/lifestyle habits and practices. Make sure you know the difference.
What to do now?
- Request an advanced lipid test. ApoB and LDL particle number testing, as discussed, can provide a lot more detailed insight in to your actual heart disease risk.
- Decrease your inflammation. Inflammation will aggravate your whole body, and can be a major driver of these conditions. Decreasing inflammation has been shown to help improve your numbers and decrease risk factors (3, 4, 7).
- Less vegetable oils, industrial seed oils, trans fats. Look at your food labels and cut down on soybean, sunflower, canola, safflower, and peanut oils. These are susceptible to oxidation and will drive that particle number up.
- More vegetables. I don’t think I need to say more here, right? EAT YOUR GREENS.
- Move more!
- Stop smoking.
- Practice stress-management. Meditate, journal, breathe deeply for a few minutes a day, color, play music, arts and crafts, GET OUTSIDE, connect with loved ones, take out the ones that stress you out, etc. Whatever works for you, do that!
- Reduce sugar in the diet. Eating less grains (especially refined) and sugars has shown promising results in lab values for folks with high cholesterol (2, 3, 8).
- Eat high-quality animal-based omega-3 fats. Research suggests 500 mg a day may lower your total cholesterol and triglycerides and sometimes increases your HDL (3); eggs and wild fatty fish or supplements like cod liver oil can be excellent sources
- Eat high-quality fats. Olives, olive oil, coconut milk, coconut oil, raw dairy products (if tolerable), avocados, raw nuts and seeds, grass-fed meats, pastured organic eggs (lightly cooked to avoid oxidative damage-think runny yolks). All the fats have certain smoke points to note, too. For example, if you are going to bake, roast or stir fry on a high heat, coconut oil or avocado oil is best. Olive oil has a relatively low smoke point and shouldn’t be used with high-heat cooking as it will damage the fat and oxidize.
- Get a basic test done, and look at the ratios. Evaluate your current lifestyle/diet, and go see a healthcare practitioner or dietitian to get help in prevention/treatment interventions.
- Total Cholesterol/HDL: indicates how long LDL is hanging in the blood. Lower is better.
- 3.5:1 or less
- Triglyceride/HDL: can be a marker for insulin resistance
- 1:1, 2:1; lower is better
- Total Cholesterol/HDL: indicates how long LDL is hanging in the blood. Lower is better.
There you have it! Cholesterol is complicated, and every body is so different with how it responds to dietary cholesterol based off what else is going on in the body. It is SO important to address all possible factors to determine root causes for conditions. Otherwise you are just chasing the symptoms and hurting your body in the process. I will get into statins at another date, as there is just too much to cover in one post! Have a great week,
Therese Martinez, MS, RD, CPT