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Saturday
Mar312012

Cholesterol, Health and Heart Disease


For decades, sound bites on the news, daytime television and mainstream magazines have warned us of the dangers of fat and cholesterol. When it comes to our heart health and risk of future disease, we’re often told:

  • High cholesterol is a sure sign heart disease is right around the corner
  • We should limit or eliminate dietary cholesterol to lower our blood cholesterol levels
  • Fat, especially saturated fat, should be avoided because it can clog our arteries
  • When diet and exercise don’t bring cholesterol levels to a “healthy” level, statins should be prescribed (or they’re prescribed before focusing on diet and lifestyle changes)
  • Whole grains should be increased in the diet to help reduce cholesterol levels, which will lower heart disease risk

Though these all seem logical based on what we’ve been told about fat, cholesterol and heart disease, thorough reviews of the research from the past several decades shows the statements above are not true. If the above advice doesn’t improve health, could it possibly increase the chance of disease?

Several important books have been written on this subject, so it won’t be possible to go into the kind of depth this subject requires in a few articles alone. If, after reading the following articles, you’d like to delve into this topic even more, I recommend the following books: Good Calories, Bad Calories by Gary Taubes, The Great Cholesterol Con by Anthony Colpo, Ignore the Awkward! by Uffe Ravnskov and The Art and Science of Low-Carbohydrate Living by Jeff Volek and Stephen D. Phinney.

This topic is much larger than most people realize. There is more to it than the sound bites we hear in the news. I’ll break up the topic over a series of articles to cover:

  • What cholesterol is, how it got its reputation and what we learn from measuring it
  • How diet, exercise and lifestyle affect cholesterol and health
  • How a dysfunctional metabolism affects lipid profiles and what to do about it

I also want to stress that regular blood tests are important in monitoring one’s health. A very small percentage of the population makes comprehensive blood testing a priority. I also highly recommend working with a registered dietitian and a fitness professional as many of our health issues can be resolved through nutrition, supplementation, lifestyle changes and exercise. These options come without the side effects of drug therapies. That said, if you are on drug therapies, always check with your physician before modifying your drug therapy plan.

Cholesterol 101

Most of the cholesterol in your body is made by your body, not from your diet. Cholesterol is critical for the formation of hormones, including sex hormones like testosterone, and is necessary for creating bile, which is critical for the digestion of fat.[i] A significant amount of cholesterol is found in the brain, where it’s used for nervous system function. Cholesterol is found in all animal cells and is a precursor to vitamin D.

Cholesterol is a waxy substance. It is not water-soluble and must be carried throughout the body bound to a protein called lipoprotein. Though we often think of HDL and LDL as cholesterol, measurements of the two are actually measures of the cholesterol-protein compound.

To get a good understanding of cholesterol’s important roles in the body, one needs to look no further than the side effects from statins, drugs that reduce cholesterol formation in the body. Though statins do lower heart disease risk in some people, emerging belief is that their effect is not because they lower cholesterol, but because they lower levels of inflammation. Inflammation, not cholesterol, is thought by many to be a major trigger of heart disease.

According to WebMD, some of the mild side effects include headache, skin flush, muscle aches, weakness, nausea, digestive issues and abdominal cramping. Since cholesterol is used for producing testosterone, it’s no surprise statins can lower testosterone levels as well.

Statins now carry a warning about the fact they may raise blood sugar levels, possibly increasing the risk of developing insulin resistance or diabetes. In addition, according to the FDA, statin use may cause confusion and memory loss. While brain function may be improved if one stops using the statin, it does make you wonder what long-term use may do to the brain. Their negative effect on brain function is not surprising since a large portion of the body's fat and cholesterol is found in the brain.

Cholesterol is critical to a healthy metabolism, so lowering it in otherwise healthy individuals could be dangerous.

How did cholesterol get its bad reputation?

Cholesterol was first implicated as a factor in atherosclerosis in the 1930s, when experiments on rabbits showed that feeding them cholesterol caused a type of atherosclerosis almost like in humans. However, rabbits never eat foods containing cholesterol since they are herbivores. It was later admitted this was not a good model for diet and its effects on cholesterol and heart disease, but some overlooked the fact that it wasn’t a good test.[ii]

Epidemiological studies have shown a correlation between elevated cholesterol and increased heart disease risk when comparing one population against another, yet when researchers look at individuals within a population, the relation between cholesterol levels and heart disease tends to disappear. This suggests that other factors between the two populations could be the reason for the difference in heart disease risk, as well as the difference in average cholesterol levels.

It wasn’t until research on statins was published that researchers had something to support the idea that lower cholesterol levels decreased heart disease risk. They came to this conclusion because statins lower cholesterol, and statins reduce mortality risk from heart disease, so if statins lower cholesterol and reduce mortality, then lowering cholesterol must reduce mortality. Do you see the flaw in the logic?

Here is another example of that type of logic. Presumably, more Americans drive cars made in the United States than any other country. In Japan, the Japanese drive more Japanese cars than American cars and have a lower rate of obesity than Americans do. Therefore, there must be something wrong with American cars that they cause obesity, so maybe more people should buy foreign cars. Though there is an association between the two variables, no one would think to suggest that American cars cause obesity. However, this type of logic has been used against cholesterol for decades.

There is an association between high cholesterol and heart disease, and there is some benefit to statin use which also lowers cholesterol levels, but that does not mean attacking cholesterol is the answer to improving heart health. Instead, cholesterol levels can serve as a sign something is awry with one’s metabolism.  Looking at the makeup of one’s lipid profile can help provide some clues.

The Components of a Lipid Profile

The least valuable number in a lipid profile is total cholesterol yet, when discussing the topic, people often ask one another, “What’s your total cholesterol?” Asking such a question is like asking a pro football running back what his weight is. It makes no difference unless you know his height and body fat percentage.

At a high level, total cholesterol can be broken down into HDL, LDL and triglycerides. Each of these components has a different role in metabolism.

High-density lipoprotein, often dubbed “good cholesterol” is cardio-protective, meaning the higher it is, the lower your risk. HDL carries cholesterol back to the liver where the liver disposes of it. Levels of HDL are increased through exercise, weight loss, moderate alcohol consumption, reduced consumption of carbohydrates and increased consumption of certain fats, including saturated fat. HDL is so affected by carbohydrates in the diet that “researchers have lately taken to using HDL as a way to determine the amount of carbohydrates that their clinical-trial subjects eat.”[iii] The more carbohydrates one consumes, the lower the HDL levels tend to be.

Low-density lipoprotein often gets the most attention and has the unfortunate reputation of being “bad cholesterol.” Very high levels of LDL are associated with an increased risk of cardiovascular disease, but the cholesterol itself is not likely the problem. Instead, the issue that drives up LDL levels is also likely the issue that causes heart disease.

Common belief is that damage has taken place in the blood vessels which increases inflammation as part of the healing process. Cholesterol is used in this healing process, so levels can be elevated in response to the injury. LDL comes in different-sized particles; the smaller they are, the more atherogenic they are. Small, dense LDL particles may make heart disease worse. Processed carbohydrates, especially sugar, create smaller, denser LDL particles. Saturated fat, on the other hand, causes LDL particles to become large and fluffy. Large, fluffy LDL seems to have no effect on heart disease risk.

Another factor in the development of heart disease is the oxidation of LDL. The longer LDL floats around the blood without being used, the more prone it is to free radical damage, which causes oxidation. The common visual example of oxidation is when metals rust.

Similar reactions take place inside the body, which is why antioxidants play such an important role in our health. When LDL is excessively high, especially compared to HDL, there is a greater possibility LDL can be oxidized. Lipid expert Chris Masterjohn goes into much greater detail on this topic if you’re interested.

We have one more common lipid measure to discuss, and this measure could be the most telling of all for cardiovascular disease risk. Triglycerides are the storage forms of fat in the body. With that being the case, one may think eating a lot of fat will increase triglyceride levels, but that’s not the case. An excessive amount of carbohydrates in the diet is what drives up triglyceride levels. Elevated fasting triglyceride levels can also be a sign that an individual has a high percentage of small, dense-particle LDL.

Lipid Ratios

Much confusion exists about the levels of cholesterol in the blood. Generally, more is better for HDL, less is better for triglycerides, and LDL by itself may not matter. Though drug therapies are often recommended based on hard numbers, using ratios of the numbers seems to provide more information than looking at the numbers alone. Two commonly used ratios are the ratio of LDL to HDL, and the ratio of triglycerides to HDL.

The LDL to HDL ratio provides a sign of how much cholesterol is being produced and moved out to the body compared to the amount that is returned to the liver for disposal.  As mentioned above, it can indicate the likelihood that LDL is being oxidized. The ideal LDL to HDL ratio is:

Another valuable ratio is the ratio of triglycerides to HDL. High triglyceride and low HDL levels both increase the risk of heart disease. The lower the ratio, the better. Beyond heart disease, a high triglyceride to HDL ratio can also be a sign of insulin resistance. In recent studies, this ratio was shown to be the best predictor of future cardio events.

Beyond Basic Lipid Profiles

If you do have a basic lipid profile, which includes LDL, HDL and triglycerides, and the results are abnormal, you should request more comprehensive testing before deciding on a course of action. Too often, people make, or are told to makes critical decisions about their health based on a basic lipid profile.

When LDL levels are elevated, ask your doctor to order a VAP test or order one yourself at Life Time. This detailed lipid test analyzes the particle size of each of the lipids, as well as measures additional markers such as lipoprotein(a) and Apoprotein B, LDL and HDL particle size, and the LDL density pattern.

As mentioned above, a high level of small, dense-particle LDL can be a concern. LDL pattern can be Pattern A which is large and fluffy, or Pattern B, which is small, dense, atherogenic LDL. On a personal note, I had my Premium Longevity & Vitality test completed in May of 2011. It showed my LDL was Pattern B. I knew my nutrition and exercise plans were excellent. However, I was not getting enough sleep and was not dealing well with stress. For the next nine months, I focused on those two areas of my lifestyle. When I had my test done again in February of this year, my small particle LDL levels dropped significantly and I’m now Pattern A, which means the size of my LDL particles has changed, which has lowered my risk of heart disease.

The table below shows the comparison from 2011 to 2012. You can also see how much of an effect the lifestyle changes had on my triglycerides as well. I’ve only shared part of the list of items measured in my Longevity & Vitality lab test to keep the focus on lipids. In future articles, I’ll talk about some of the other measures included in the assessment and what can be learned from them.

Three other markers you should have measured related to the health of your heart include your fasting glucose, C-Reactive Protein and Homocysteine. Fasting glucose can be an indicator for insulin resistance and the chance of developing type II diabetes. Homocysteine and C-Reactive Protein are indicators of inflammation and, as we’ll discuss in a future article, inflammation may very well be the cause of heart disease as well as the reason statins have been shown to be beneficial in a very small percentage of the population.

Summary

To quickly summarize, high-carbohydrate diets reduce HDL and increase small, dense LDL levels. Excessive carbohydrate consumption can even increase the total amount of LDL particles in the blood, making them more prone to oxidation. You may be thinking ahead already and realizing that eating a low-fat, high-carbohydrate diet, especially a diet of processed foods with “heart-healthy” label claims may be doing just the opposite of what you thought. According to the research, that could be the case. This is what we’ll address next week.

Share thoughts and comments below.

Written by Tom Nikkola - Director of Nutrition & Weight Management

This article is not intended for the treatment or prevention of disease, nor as a substitute for medical treatment, nor as an alternative to medical advice. Use of recommendations in this and other articles is at the choice and risk of the reader.


[i] Lecerf J-M, de Lorgeril M. Dietary cholesterol: from physiology to cardiovascular risk. Brit J Nut. 2011;106:6-14

[ii] Gary Taubes. Good Calories, Bad Calories. 2007

[iii] Gary Taubes. Why We Get Fat. 2010. Random House, Inc. Kindle Edition

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Reader Comments (10)

The text says "The ideal HDL to LDL ratio is:", but the table immediately below that shows "LDL/HDL ratio". Clearly one is wrong.

Is it HDL/LDL or LDL/HDL?

April 1, 2012 | Unregistered CommenterCarlos

Thanks for catching that Carlos. It's LDL/HDL. I'll get that fixed.

April 1, 2012 | Unregistered CommenterTom Nikkola

Is it possible without ..side effects

April 2, 2012 | Unregistered Commenterlipotrim

As far as the ratio of triglycerides to HDL, you said the lower the better. The next sentence said "a low triglyceride to HDL ratio can also be a sign of insulin resistance". How can both be true?

April 2, 2012 | Unregistered Commenterwindancer

@windancer: Yikes. That was a typo, even after rereading it many times, I missed that. Sorry. A high triglyceride to HDL ratio can be a sign of insulin resistance. Thank you for catching it. I've corrected it.

April 2, 2012 | Unregistered CommenterTom Nikkola

So a low carbohydrate is the best way to reduce your chances of getting diabetes and decreasing the inflammation that gives you heart disease?

April 2, 2012 | Unregistered CommenterGracie

@Gracie: There may be other factors beyond diet, which we'll cover in future articles, but there's plenty of evidence to show reducing carbohydrates, especially processed carbs, can have a positive effect on heart disease risk.

April 2, 2012 | Unregistered CommenterTom Nikkola

I've been on statins for several years after trying unsuccessfully to lower my cholesterol with diet and exercise. I smoked too though, which lowers HDL (HDL helps keep LDL lower). I have a family history of Type II diabetes on both sides and alzheimers on one side so have concern about the statins long term. Do you know of research that weighs the pros adn cons of using statins?

April 2, 2012 | Unregistered CommenterGail

@Gail: It's wise for anyone considering statin therapy to weigh the pros and cons. Most research shows statin use does not benefit women. A meta-analyses was published in February in the Journal of the American College of Cardiology stating it showed statin therapy did benefit women, and even though they use the term "statistically significant" to suggest statin therapy provided a large decrease in mortality, it's a little misleading because the difference between those who used statins and placebos is not dramatically different. There are many known side effects, so be sure to talk about them with your doctor. I'd recommend the book "The Cholesterol Con" as mentioned in the article, as it does a thorough review of research on statins and their pros and cons. In the end, if there is a slight benefit, it must be weighed against the risk of long-term use of statins. With serious decisions like this, it's always a good idea to get a second opinion to make the best decision for your long-term health. Chris Kresser also wrote a good article on statins you might want to check out: http://chriskresser.com/the-truth-about-statin-drugs. At a minimum, be sure to supplement with Coenzyme Q10 as statins dramatically reduce this important nutrient.

April 2, 2012 | Unregistered CommenterTom Nikkola

As I understand (HDL) it does not take cholesterol to the liver to get rid of it, it takes it to the liver to recycle it. CHris masterjohn and other have pointed out flaws in the theory that HDL is ythe so-called "good cholesterol"..the main flaw being the research that has failed to show benefits of raising HDL in a variety of studies including the catastrophic failure of "Torcetrapib"(CP-529,414) a drug that very successfully raised HDL.

On December 2, 2006 Pfizer cut off torcetrapib's phase III trial because of "an imbalance of mortality and cardiovascular events" associated with its use.[15] This was a sudden and unexpected event and as late as November 30, 2006 Jeff Kindler, Pfizer’s chief executive, was quoted, "This will be one of the most important compounds of our generation."[15] In the terminated trial, a 60% increase in deaths was observed among patients taking torcetrapib and atorvastatin versus taking atorvastatin alone.[16] Pfizer recommended that all patients stop taking the drug immediately.[17]Six studies were terminated early.[5] One of the completed studies found it raised systolic blood pressure and concluded "Torcetrapib showed no clinical benefit in this or other studies, and will not be developed further.

The aftermatch of this trial raised serious doubts on whether the theory of "good cholesterol" could be kept alive.

July 12, 2012 | Unregistered Commenterdavid ramsey

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