Everything you know about Cholesterol is (at least) Incomplete & What You Can Do About It
Updated: Jul 23, 2020
*As always, scroll to the very bottom for a TLDR synopsis*
Cholesterol has a bad rap, and you've probably bucketed it into two categories; "good" and "bad" cholesterol. You've been told that your cholesterol levels are creeping up, so you watch your saturated fat intake. But like most of society you've been duped, because it's not that simple, and saturated fat is not the root of all evil. In fact, everything that you've been told about saturated fat, cholesterol, and cardiovascular disease is (at best) incomplete. Luckily things are changing and comprehensive tests are becoming more routine (at least in integrative medicine offices). I will include important tests that you may want to discuss with your doctor, if you are concerned about your cardiovascular health.
Research shows that cholesterol is a symptom of heart disease and NOT the cause, as we've been led to believe. In fact, LDL or "bad cholesterol" isn't even cholesterol, its a vessel that carries fat-based energy to your cells. Cholesterol is one of many passengers on this LDL vessel. Cholesterol's job is to fix your cells. YOU NEED IT. Now, why is this so confusing? Well in the world of higher fat diets (& lower overall carbohydrate intake), you will have high LDL and this is actually a good thing. More LDL means more fatty acids to fuel your cells, which means increased energy for you. If you're in good health, your cells don't need constant cellular repair. Your body can use cholesterol for other things, like balancing your hormones. Now, what about with heart disease?
The misconception of LDL cholesterol causing heart disease is a prime example of correlation vs. causation, and one that has catapulted generations into a fat-fearing frenzy while wrecking the health of populations. Your arteries circulate blood throughout your body and when your arterial walls are damaged, cholesterol fixes the damage. Here in lies the misconception. LDL particles are large and they can get stuck in the tears of your arterial walls. Plaque starts to form and BOOM heart disease. Correlation vs. Causation; plaque is the result of something getting stuck that leads to heart disease, not the fact that LDL was present (and trying to fix the damage in the first place). The real question is, what is damaging your arteries in the first place? What is creating the tears in your arterial walls where LDL particles are getting stuck and plaque is forming? Eradicate the underlying cause and you eradicate the actual problem, not a symptom of the problem. The real problem and the cause of these arterial tears is chronic inflammation overload. Inflammation causes the damage to your arterial wall, cholesterol comes in to fix the problem and gets stuck at the damaged site, becoming the scapegoat for heart disease. So now...we've got a population trying to lower their LDL cholesterol levels while not addressing the root issue. Is it any wonder why heart disease is such an issue today? We have chronic inflammation overload tearing up our arterial walls and decreased levels of important molecules needed to patch up these tears.
"The more I reviewed the literature, the more I realized, 'You know what? It seems like everything they teach us in nursing school, in medical school, in pharmacy school about lipids, about LDL, about VLDL, and HDL, the good cholesterol, the bad cholesterol, and how the stuff works--it's probably wrong, or at least incomplete."-Dr. Zubin Damania. Dr. Damania is a primary care clinical director and internal medicine doctor at Stanford. Dr. Damania is helping to shed light on the demonization of cholesterol and is one of too few trying to change the perception of cholesterol's role in heart disease. Especially if you are on a lower carbohydrate and higher fat diet, higher cholesterol levels are not necessarily a bad thing. Fighting inflammation is actually what you need to worry about to achieve ultimate health.
Let's take a closer look at what is really going on. When you follow a higher-carbohydrate intake (respective to other macronutrients), you are getting the majority of your energy from glucose. The carbohydrate that you ingest is digested into glucose, and is sent through your bloodstream to cells with some help from insulin. Because your blood is primarily water, glucose gets dissolved without issue- think stirring sugar into water. If you are following a higher-fat intake (respective to other macronutrients), you are getting most of your energy from fat. Fat is not like glucose. The fat that you eat digests into fatty acids, but fatty acids cannot be sent through your blood like glucose because fats and liquids do not mix (think trying to dissolve oil in water). Instead, fat must be carried through the bloodstream to reach your cells. To do this your body must:
1) package fatty acids into triglycerides (a bundle of three fatty acids) to make it easier for them to be transported through your blood.
2) create carriers to transport these triglycerides.
These carriers are lipoproteins. Lipoproteins carrying a load of triglycerides are called very-low-density lipoproteins (VLDL) and lipoproteins that have already dropped their triglycerides are called low-density lipoproteins (LDL). Unfortunately, LDL has been deemed "bad cholesterol." LOL. LDL isn't even cholesterol! So...what is cholesterol?
Cholesterol is a passenger in LDL and if you're in good health, it rarely leaves the LDL carrier. LDL carriers really only have cholesterol in them for emergency repair, because a main function of cholesterol is cellular repair. Because LDL carries fat-based compounds to hungry cells, by definition, your LDL levels will go up if you are on a high-fat diet. This is a good thing because it means that you have more fatty acids to transport through your bloodstream to deliver as energy to your cells. If you don't need constant cellular repair, the unused cholesterol can be bundled into high-density lipoprotein (HDL) particles and directed to your liver to create sex hormones- this is one reason why a higher fat diet is good for testosterone production.
If high cholesterol levels do not cause heart disease, what does? The answer is chronic inflammation. Elevated levels of inflammation cause arterial wall damage. LDL transports cholesterol to the damaged site to repair it. Because LDL carriers are large, they can get stuck at the damaged site and consequently plaque begins to build up. Therefore the answer is not to decrease your LDL levels and thus your body's ability to repair itself, but to eradicate whatever is causing the arterial wall damage in the first place. "Elevated levels of cholesterol" are a symptom of a larger issue.
To date the most influential study in determining heart disease risk factors was the Framingham Heart Study. The Framingham Heart Study began in 1940 and followed many generations collecting data on their heart health. While The Framingham Heart Study is incredibly useful for learning about heart disease, there are aspects of the study that can be misinterpreted. According to the study, the main risk factors for heart disease are: high cholesterol (LDL) & arterial plaques, smoking, obesity, lack of exercise, high blood pressure, and psychological stress. Now here's the kicker....every single one of these risk factors except LDL (debunked above) is associated with, or is the cause, of inflammation and inflammation damages arterial walls. Chronic inflammation destroys artery walls, cholesterol carrying LDL shows up to do some damage control, gets stuck in the arterial wall tears, and becomes the scapegoat for being the cause of heart disease.
Fortunately, more and more researchers and doctors like Dr. Damania are questioning preliminary assumptions about the Framingham Study and taking their concerns mainstream. If you are concerned about your cardiovascular health, below are some tests and concerns to ask your doctor about:
Oxidized LDL cholesterol: these particles get stuck in your arteries & your immune system mistakes them for invaders, leading to inflammation in your arteries.
Stop eating fried foods, cut your sugar intake, & keep your inflammation down
Low HDL (high-density lipoprotein) cholesterol: HDL assists in transporting cholesterol from arteries & tissues for metabolism.
Eat more high-quality saturated fat
Small dense LDL (low-density lipoprotein) cholesterol: this is LDL cholesterol that is smaller & heavier than other LDL particles, this type spends more time in the is more likely to oxidize.
High levels are associated with risk of atheroscierosis
High triglycerides: fatty acid molecules that are bonded with a glycerol, measured in the bloodstream.
High levels could indicate cardiovascular disease risk or metabolic syndrome
High triglycerides/HDL ratio: too much fat in the blood with not enough HDL to transport cholesterol for metabolism increases cardiovascular disease risk.
Non-HDL Cholesterol: total cholesterol - HDL. Without HDL to transport cholesterol for metabolism, other forms can start to clog up arteries.
Most concerning if triglycerides are also high
Fasting insulin/-glucose: measures your insulin sensitivity - how well you metabolize the sugar you consume.
Higher numbers can indicate insulin resistance
APO A-1 (Alphalipoprotein A-1): important to cholesterol transport.
Higher levels are associated with lower occurrence of cardiovascular disease
APO B (Alphalipoprotein B): the protein component of LDL.
Lower levels are associated with lower occurrence of cardiovascular disease
hsCRP (inflammatory marker) High-sensitivity c-reactive protein: the liver makes C-reactive protein when there is inflammation in the body.
Chronic elevation is associated with cardiovascular disease risk
Homocysteine: indicates impaired conversion of methionine to cysteine.
Chronic elevation can indicate inflammation and is associated with cardiovascular disease risk
Lp-PLA2 (Lipoprotein-Associated Phospholipase A2): Lp-PLA2 is an enzyme that marks inflammation of blood vessels (which is significant to atheroscierosis).
If anything is damaging your arteries, Lp-PLA2 will increase
In addition to understanding that high cholesterol is the symptom of a larger problem, and not the cause of the problem itself, it is important to understand the factors affecting your LDL cholesterol response numbers. These factors include; individual wiring (your body's response to dietary fat is unique), obesity, insulin resistance, diabetes, Hypertrig