This is the third year in a row I am giving community talks on cholesterol and it is clear that this topic is one of the most popular, year after year. I think this is because “high cholesterol” is one of the easiest medical conditions to diagnose and is aggressively treated. I mean, statin medications like Lipitor did not become the top-selling drug (1) (at $7.2 billion!) and simvastatin (94.1 million prescriptions!) the second most-prescribed drug (1) in the United States for no reason!
I’m writing this blog because I want to bring to light the reality of health and cholesterol and bust some of the myths in this area!
I was originally going to name this blog “The Cholesterol Myth” but I guess I’m not the only person who thought that was a catchy title, because I found this book, The Great Cholesterol Myth which covers the same topic. I haven’t read the book, but it looks interesting!
What is cholesterol?
When people talk about “cholesterol,” they are usually actually talking about fat in the blood, either carried by lipoproteins (proteins that escort fat around) or as lipids. There are three kinds:
- LDL (low density lipoprotein): Often called “bad cholesterol,” this type of lipoprotein carries cholesterol from the liver to tissues, so the thinking is that it can “build up” where it shouldn’t be (ie: arteries).
- HDL (high density lipoprotein): Often called “good cholesterol”, this type of lipoprotein does the opposite of LDL; it carries cholesterol from tissues back to the liver where it is broken down or eliminated from the body. HDL is considered to be preventative of disease.
- Triglycerides: These are literally fats in the blood. Extra calories in the body are converted into triglycerides and stored in fat cells for a “rainy day” when your body might need more energy.
Why is cholesterol bad?
Coronary atherosclerosis (aka “hardening of the arteries”) “occurs when fat, cholesterol, and other substances build up in the walls of arteries and form hard structures called plaques (2).” These plaques decrease blood flow through arteries by taking up space and making the artery walls less flexible. They can also grow so large they completely block blood flow or pieces of them can break off and also causes blockages. Blockages like this can cause heart attacks and strokes.
The extra-simple explanation for why your doctor and the media care so much about your cholesterol numbers is that they believe that high total cholesterol is an important risk factor that predicts atherosclerosis. Therefore, prescribing medication to lower cholesterol can prevent atherosclerosis and its consequences. This approach still ignores WHY cholesterol is elevated and how such causes can also contribute to atherosclerosis in many other ways… I’ll get to that later.
So, if plaques in arteries are a problem, how can we measure them? Turns out this is not so hard! There are good imaging techniques to help measure coronary plaques (plaques in the arteries feeding blood to the heart muscle), such as Electron Beam Tomography (EBT) and computed tomography (CT) angiography (3). The most risky plaques are calcified, which makes them easier to see via such imaging.
Cholesterol reality check
So, the next logical question is, does elevated cholesterol correlate well with arterial plaques? And therefore, is cholesterol a useful measure to assess risk of coronary atherosclerosis? The answer is NO.
Last year I read a great article called “Does cholesterol drive coronary atherosclerosis?” (3) in Integrated Healthcare Practitioners magazine summarizing a great deal of evidence from many other sources over years. Here are a few highlights:
- Total cholesterol and LDL cholesterol do not correlate with coronary artery calcium burden or total plaque burden (calcified or not).
- The commonly accepted idea that saturated fat in the diet leads to atherosclerosis has been repeatedly challenged and is not supported by research literature. This article points out that “increased saturated fat intake leads to a beneficial decrease in small dense LDL, and greater intake in saturated fat was found to reduce progression of coronary atherosclerosis (4).”
- Lower LDL does not reduce the prevalence or progression of coronary plaque.
- Treatment with statins does not affect coronary calcification.
- For women, men over 47, and the elderly in general, elevated cholesterol is a “very weak risk factor” for coronary heart disease or “not a risk factor at all.”
Statins: risky business
So what is up with anyone and everyone taking statin medications? Some young doctors start taking these medications “preventatively” and some doctors have gone as far as to suggest that every adult should be on them!
The reality is that statin medications block cholesterol production by interfering with a natural process in the body (ie: the way most pharmaceuticals work). This is not insignificant, as your body is created to work efficiently and healthily given a supportive environment. Changing this environment and important processes such as this not only ignores the real issue of WHY is the body producing higher levels of cholesterol but also leads to a huge list of adverse effects.
I recently read a blog Possible pitfalls of statins which highlights some of the important consequences of taking these medications – check that out for more info.
How can we better understand cardiovascular risk?
We’ve established that total cholesterol and LDL are not as useful for predicting risk as previously believed, so now what? Another great article “Novel cholesterol subtypes” in Integrated Healthcare Practitioners magazine looks at evidence for several lesser-known lipid markers to asses risk. Here is a brief summary of each from this article:
- Lipoprotein-associated phospholipase A2 (Lp-PLA2): Can be a strong predictor of cardiovascular events (eg: heart attack, stroke) and can be reduced via omega-3 fatty acid intake and weight loss.
- Apolipoprotein (Apo) B: Can more accurately pinpoint the number of LDL particles and therefore can better estimate risk.
- LDL particle concentration (LDL-P): Another measure of the number of LDL particles, as above.
- Lipoprotein(a) (Lp(a)): Number of these molecules is a strong predictor of cardiovascular risk, especially in patients with strong family history.
- LDL and HDL subfractions: Seek to understand more detail about size, density, and cholesterol content of LDL and HDL. These measurements appear to be less useful than other tests listed above.
In addition to lab testing alone, there are many other risk factors for cardiovascular disease to be considered:
- Extent of calcified plaque in arteries (measured as described above via EBT or CT)
- Hypertension (elevated blood pressure)
- Diabetes and insulin resistance (which is the result of long-term blood sugar dysregulation)
- Being overweight or obese (result of long-term excess calories stored as fat)
- Inflammation in the body (can be measured using tests such as high sensitivity CRP (hs-CRP))
- Lack of physical activity
- Stress (lots of evidence that stress plays a major role in developing heart disease)
- Mood (depression also increases risk of heart disease!)
Heart health, naturally
So many patients are worried about cholesterol and I am really disappointed to observe that often this fear and anxiety is fostered by their medical doctors. I’ve become tired of hearing that my patients feel forced or even “bullied” into taking statin medications while not being fully informed about the true risks and benefits of these medications. Most of all, I feel frustrated that as a society, we do not use cholesterol information as a CLUE to what is out of balance about a patient’s diet, lifestyle, health, etc and work on these issues instead, which actually make a major impact on long-term health and wellness.
High cholesterol, atherosclerosis, heart disease, etc are the result of a lifetime of choices and are almost entirely preventable. Naturopathic treatment in this area is highly personalized, but should take into account:
- Nutrition and diet changes appropriate to the individual
- Weight reduction where necessary
- Consistent and challenging physical activity
- Appropriate stress and mood management
- Reversing conditions which promote heart disease, such as insulin resistance and inflammation in the body
- Healthy function of the liver, which produces cholesterol
- Treatment for other risk factors as listed earlier (eg: smoking cessation, blood pressure regulation)
- Appropriate nutritional and botanical supplementation for the individual
- Ware WR. Does cholesterol drive coronary atherosclerosis? Integrated Healthcare Practitioners. 2011 Oct: 64-68.
- Accurso A, et al. Dietary carbohydrate restriction in type 2 diabetes mellitus and metabolic syndrome: time for a critical appraisal. Nutr Metab (Lond). 2008 Apr 8;5:9. PMID: 18397522
- Habib C, Rouchotas P. Novel cholesterol subtypes. Integrated Healthcare Practitioners. 2012 Oct: 53-57.