I recently gave a seminar for an educated group of my patients and various health practitioners including doctors and nurses. It was titled ‘Cholesterol – A convenient villain’.
This topic was highly relevant to everybody in the room, who’s ages ranged from mid 20’s to some in their 70’s.
The reason so many people are interested in cholesterol is that current guidelines recommend treating all people who are high risk for a heart attack with lifestyle interventions and cholesterol lowering drugs called statins.
By the way, your cholesterol level is the major determing factor in defining high risk.
The recommendations were originally intended for those who have already had a heart attack, and want to prevent a second (secondary prevention). In the new guidelines, however, doctors are recommending statins for people who have never had a heart attack, and want to prevent the first one from occuring (primary prevention)
This is particularly troubling to me, since the data on primary prevention of a heart attack with statins is nowhere near as strong as the data is for secondary prevention.
We also know there is a risk with taking statins, as they are associated with muscle breakdown, dementia, and increased incidence of diabetes.
Therefore, it is prudent to understand what cholesterol does and why we should think before we lower it.
What is the role of cholesterol?
Cholesterol is a crucially important compound, which our body makes to transport all sorts of compounds in and out of cells.
Our cells have a structure that is repeated over and over in biology. They have an outer ring, which is composed of lipids (fats) and an inner structure that is water soluble. In order to get compounds in and out of cells, we require a fat-soluble carrier, and cholesterol is the perfect design.
Other than transport in and out of cells, cholesterol is a backbone structure for the production of neurotransmitters, vitamin D, and hormones. I cannot over-emphasize the crucial role that these compounds play in our existence.
If cholesterol has so many important roles, why have we been led to believe that it is bad?
It all started with a rise in heart disease that was noticed in the 1950’s. Policy makers from the food and drug administration needed to establish some control over the rising problem, and needed a focus point for their strategy.
Around this time, a man named Ancel Keyes was put to the task of conducting a study, which evaluated the link between high fat diets and heart disease. He ended up publishing the famous 7 countries study, which showed a clear link between intake of dietary fat and heart disease.
This data looked impressive, but only told part of the story. What was uncovered many years after the data was accepted was that his data related to 22 countries, not 7. When the statistical correlations were performed, there actually was no statistical significance to the relationship.
Nonetheless, the data was accepted, and it spurned the ‘low fat craze’ of the 1980’s that has continued until today.
Although there is some merit to lowering the intake of fats in our diets, the end result of the ‘low fat craze’ was:
- Replacement of saturated fats with highly inflammatory vegetables oils, such as canola and soybean
- A huge rise in the consumption of sugars and refined carbohydrates
- A steady increase in the incidence of diabetes and metabolic syndrome
- An obesity epidemic
As our health institutions were noticing the increase in obesity and diabetes, publically funded studies such as the Lyon diet heart study and the Nurses health study were reporting that dietary fat and blood levels of cholesterol did not appear to be linked to heart disease.
Despite all of these factors, the cholesterol theory gained more traction, and proceeded forwards.
How does heart disease start, and how does cholesterol fit in?
The process of heart disease is one of the most widely studied areas in medical history. Although there is controversy on the exact mechanism of action, most experts agree that it starts with endothelial damage.
The endothelium is a one-cell layer lining on every blood vessel in the body. It is very strong and resilient. It can however succumb to shearing forces exerted by adverse physiology in the body. The 3 contributing causes of break-down of the endothelium are:
- Oxidative stress or free radicals
- High blood sugar levels
- Chronic inflammation
Once the endothelium is damaged, the body goes into an immediate stress response. In order to fix the damaged endothelium, our body sends in cholesterol to bring in the necessary factors for healing.
Cholesterol is actually sent to the site of damage to help in the repair process.
As long as further damage does not ensue, the cholesterol will simply bring in healing factors, and in the early stages, blood vessels do have the capacity to heal. However, in most cases, the poor lifestyle choices continue, and do not provide a healing environment.
In this case, that person will cause oxidation of the cholesterol, and it will subsequently deposit into the endothelial layer. This progressive deposition of cholesterol and calcium in the endothelium are the hallmarks of heart disease.
What risk factors should be analyzed in heart disease?
My evaluation of heart disease relies on a combination of risk factors, of which cholesterol plays a modest role.
In my experience, I have found the following markers to be useful when I evaluate someone for heart disease:
- Fasting glucose and insulin
- Lipoprotein a
- Cholesterol particle number and size
- Blood pressure
- Waist:Hip ratio
All of these factors can be checked from your local lab through a doctor’s visit, except cholesterol particle number and size, which is conducted at a specialty lab.
What is the take home message about cholesterol?
The bottom line is that cholesterol is our friend, not our foe. It is in our bodies to help us create the necessary processes for life.
In certain circumstances, when the process of heart disease is advancing rapidly, there can be some merit in taking cholesterol lowering medications to reduce the risk of a heart attack.
I suggest you have your condition evaluated on an individual basis, and only consider a cholesterol medication if the sum of your risk factors warrants it. You should only take these medications under the guidance of your trusted medical professional.
In the meantime, I like my cholesterol just the way it is.
Dr. Rishi Verma, MD
Latest posts by Dr. Rishi Verma, MD (see all)
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