The Scoop on Cholesterol 

Does This Sound Familiar?

So, you got your labs back and your cholesterol numbers are not quite where you thought they would be. You have high cholesterol, and your doctor is saying you might need a statin now or in the near future. Up until this point in your life, your cholesterol has always been pretty good. You feel as though you eat right, you exercise, and generally have healthy habits. You trust your doctor, but you are not quite ready to start taking medication every day to lower your cholesterol. You know that statins work to lower cholesterol, and you probably have a few friends who are taking them.

Having said this, maybe you’ve heard some not-so-great things about statins and their side effects. So, you naturally have some more questions but… surprise! Your 15-minute appointment is up, and the prescription has been sent to your pharmacy. As a patient, you might be saying, “I’m not ready to be stuck on a medication for the rest of my life. Are there ways to get my cholesterol down naturally before resorting to drugs? Can I at least try to get my numbers down naturally?” It always seemed reasonable to us (in most situations), and the same goes for many providers out there.

Let’s break this situation down a little more:

Hint: (To better understand the following you may want a quick refresher on the Basics of reading your lipid panel.)

The Debate

Believe it or not, cholesterol is one of the more controversial issues in medicine. You may have heard different variations of the following advice to address high cholesterol:

• “Just eat the Mediterranean diet, it’s the best diet out there.”
• “You need to cut out the cholesterol and saturated fat in your diet. Say goodbye to eggs, dairy, and red meat.”
• “Go plant based. It really works.”
• “Carbs are the enemy! Go low carb and your cholesterol will improve."
• “I saw a guy on YouTube who lowered his cholesterol by going high carb.”
• “Too much sugar in the diet! Time to cut out dessert.”
• “Follow the Heart Healthy Diet from the American Heart Association. It is approved by Cardiologists.”
• “Just take the statin, the side effects are really quite rare, and they work well.”
• “It’s probably just your genetics. There’s nothing you can do besides medications.”

You may have even heard people take the opposite stance on cholesterol altogether:

• “High cholesterol doesn’t cause heart disease. It’s all a conspiracy by big Pharma to get everyone on statins. Don’t worry about lowering it.”
• “Your brain and nervous system need cholesterol to function properly. Why would you want to lower it?”
• “You know, there is research out there showing that folks with high LDL actually live longer.”
• “You should get a coronary calcium score before taking any action. If you don’t have any plaque in your arteries, your cholesterol numbers are less concerning. “

Does your brain hurt yet?

Don’t be worried if it does. We’ll do our best to try and break down the varying (and sometimes conflicting) schools of thought out there.

First, let’s dive into the evidence regarding the relationship between cholesterol and heart disease:

High LDL Cholesterol Is a Causative Agent In Heart Disease

Let’s start here, since much of what we will discuss hinges on this idea. It is abundantly clear that long term exposure to elevated LDL cholesterol is a causal factor in coronary artery disease (better known as heart disease or ASCVD). Notice we said “a” causal factor, not “the” causal factor. Heart disease is a slow-moving process that takes hold over decades and takes many more years to cause symptoms.

It is abundantly clear that long term exposure to elevated LDL cholesterol is a causal factor in coronary artery disease (better known as heart disease or ASCVD). Notice we said “a” causal factor, not “the” causal factor.

The mechanism by which this occurs is very clear, and there are numerous academic publications and statements supporting this. If you are curious, we have compiled a number of articles that can be found at the bottom of the page and we have linked to a helpful animation (done by PhysioPathoPharmaco) about how heart disease happens, found here:

Nature’s experiment

When it comes to cholesterol, nature has already put together a very convincing experiment about the relationship between high LDL cholesterol and heart disease. Consider the following:

There are people walking around today with a mutation in a single gene that causes their LDL cholesterol to be severely elevated into the 300’s or 400’s. This condition, called Familial Hypercholesterolemia or FH for short, is a devastating condition. If untreated, young people with this condition routinely die in their 20’s from massive heart attacks. These are otherwise healthy people except for their extremely high LDL cholesterol.

On the other end of this spectrum are individuals born with a genetic condition called familial hypobetalipoproteinemia (quite the mouthful). Individuals with this condition have naturally low levels of LDL, often below 50 mg/dL but some as low as 15 mg/dL. These individuals have up to a 72% decreased risk for heart disease over their lifetimes when compared to the general population.

Nature’s experiment has proven that LDL cholesterol matters and needs to be taken seriously.

The standard of care for high LDL cholesterol

From your doctor’s point of view, there are very clear practice guidelines regarding when patients should be started on cholesterol medication. Patients are stratified into risk categories based on a few different metrics and risk factors. If you are curious, go to this website and plug in your most recent numbers to find your individualized risk score:

https://tools.acc.org/ascvd-risk-estimator-plus/#!/calculate/estimate

The tool above takes multiple factors into account including age, cholesterol, blood pressure, and certain aspects of your medical history. It then calculates the probability that you will develop heart disease in the next 10 years. The results will be in percentage points. For example, a 5% calculated 10-year ASCVD risk means you have a 5% chance of developing heart disease in the next decade.

Note: If you’re wondering, typically any value over 5% with regards to your 10-year risk for heart disease will prompt a discussion about starting a cholesterol medication.

Questioning the conventional wisdom

What about the people that say LDL does not cause heart disease? Many of these individuals point to a study done in 2009 that included over 136,000 patients who were admitted to the hospital for a heart attack over a 6-year period. This study showed that just over 72% of these patients had LDL cholesterol that was considered within the goal range. For reference, the goal range at the time of this study was less than 130 mg/dL.

If you are interested, this study can be found HERE.

The results of this study would seemingly fly in the face of everything that was just outlined above. If LDL is such an important factor in heart disease how are these people with “optimal” LDL still having heart attacks! Let’s look a little closer and examine some of the takeaway points:

1: The author’s conclusion from this study was that LDL target goals should be lower to prevent heart disease.

Based on this study (and others) the LDL goal has since been lowered to less than 100 mg/dL for healthy adults, and less than 70 mg/dL for those who are considered high risk. An upper limit of 130 mg/dL was deemed too high to truly reduce the risk of heart disease.

2: Over 50% of the patients in the study had HDL cholesterol below the goal range.

This highlights the important role that lifestyle plays in heart disease. It tells us that diet and exercise are profoundly important in preventing heart disease by way of increasing HDL levels.

3: These patients had many other risk factors for heart disease.

Of the heart attack patients who had their LDL cholesterol measured when they were admitted to the hospital, these patients had the following other diagnoses:

• 54.2% of patients had high blood pressure
• 16.5% of patients had already had a previous heart attack
• 26.2% of patients had diabetes
• 30.4% of patients were smokers
• Over 30% of patients had high triglycerides
• 21.1% of patients were on cholesterol lowering medications

When patients have these risk factors, cholesterol is often aggressively lowered to reduce the risk of heart disease as much as possible. So, while many of these patients had LDL in the goal range at the time of their admission, they were far from healthy specimens. The damage had already been done long before they showed up to the hospital that day.

If anything, this study highlights the fact that LDL cholesterol is not the only contributing factor to heart disease.

4: Less than 2% of patients had both ideal LDL and HDL cholesterol.

To put this another way, 98% of patients experiencing a heart attack had either high LDL cholesterol or low HDL cholesterol.

This is the biggest takeaway for us, as it highlights how vitally important it is to live a healthy lifestyle, even if your LDL cholesterol is normal.

All about the arteries:

As important as cholesterol is, we know it is equally important that we protect the integrity of our arteries. If the insides of our arteries stay smooth and impenetrable, then the cholesterol floating by has very little chance of accumulating where it shouldn’t. If we damage our arteries though, then cholesterol can gain entrance and set up shop. This leads to plaques, and ultimately heart disease.

How does this damage occur? The following are the most common ways in which our arteries can sustain damage:

• High blood pressure
• Diabetes
• Smoking
• Processed food and junk foods
• Inflammation
• Stress
• Alcohol consumption

If there is a root cause of heart disease, it lies in the health of our arteries.

Consider the following

1: Can someone with very high LDL walk around free of heart disease?

Absolutely. They probably work very hard on modifying their risk factors and have little damage to the inside of their arteries.

2: Can someone with low LDL have a fatal heart attack?

Absolutely. They likely have a number of other risk factors that have raised their risk over the years and caused damage to the inside of their arteries.

3: Does modern medicine know everything about heart disease and how it comes to be?

Clearly not. But we have a pretty good idea.

So How Low Should We Try to Get Our LDL Cholesterol?

This really depends on who you talk to. Current guidelines recommend healthy adults aim to keep their LDL below 100 mg/dL, which is very reasonable. Others feel LDL should be much lower. As outlined in Peter Attia’s book, Outlive, Peter Libby MD, a Cardiovascular specialist and prominent voice in the field of atherosclerosis (heart disease), states the following:

“Atherosclerosis probably would not occur in the absence of LDL-C concentrations in excess of physiological needs (on the order of 10 to 20 mg/dL).”

Yes, you read that right. He feels that if the whole population kept their LDL in the 10 to 20 mg/dl range (which is roughly the LDL level of a newborn), then heart disease as we know it would more or less disappear.

To be clear, unless you are a newborn baby reading this (in which case we’d be very impressed) or one of those nice folks with familial hypobetalipoproteinemia, you will never be able to get your LDL down to 20 mg/dL without aggressive multi-drug therapy.

Note: If you are wondering if there are detrimental effects to having an LDL under 50 mg/dL, it has been demonstrated to be very safe. Our brain and nervous system still have plenty of cholesterol available to perform their vital functions. Think of this: We go through tremendous development of our nervous system during the first year of life, and our brain is perfectly content with LDL levels below 50 mg/dL.

Is the answer to put everyone on cholesterol medications?

The answer to this is a resounding “no” from us. While the arguments about keeping LDL as low as possible certainly have merit, it is not reasonable or safe to automatically start everyone on medications. As you can tell from reading this far, coronary heart disease is a long term, complex, and multifactorial process.

High LDL does not always equal heart disease, just as low LDL does not always equal perfect heart health.

What Are The Next Steps to Take If You Have High Cholesterol?

There is a lot to talk about regarding this, so we recommend scheduling a consultation with us to talk in much greater detail. Let’s go through the basics though. 

1. Ask for more testing to determine your risk.

Blood Tests:

NMR Lipoprofile blood test:

This is an advanced form of lipid testing which can provide greater detail regarding the density, size, and particle counts of your cholesterol molecules. This will give your doctor valuable information and allow them to better evaluate your individual risk. In many cases, your insurance will cover this test. The important values here are your LDL particle count (LDL-P), and your LDL particle size. Larger LDL molecules are less worrisome for heart disease typically, as these particles are less likely to become lodged in your coronary arteries. If you have many small, dense LDL particles, then it is in your best interest to decrease your LDL cholesterol.

Apo(b):

This is a simple blood test that is becoming a more reliable marker when assessing long term risk of heart disease. This test measures the amounts of certain subtypes of cholesterol (including LDL) that are more likely to lead to plaque formation (blockages in the heart).

Lp(a):

Another blood test, this is a genetically driven marker that can help determine long term risk of heart disease. It is a “sticky” particle with a long tail that when elevated leads to more heart disease as it can easily become lodged in arteries.

As it stands now, there is no drug or supplement that can reliably lower lp(a), but it is good to know about. If you have high levels, then it is more motivation to work on your other risk factors!

Imaging

Coronary Calcium Score:

A very easy test you can have done to shed more light on your risk for heart disease is a Coronary Artery Calcium Score (sometimes referred to as a CAC). This is a CT scan that looks for calcifications (evidence of plaque) within the coronary arteries in the heart. It is scored on a scale of 0 to over 2000. A score of 0 means there is no detectable calcification. The higher the number above 0, the more calcium you have built up in your coronary arteries. We should all be aiming for a score of 0.

Unfortunately, insurance will not cover this test. Cash prices vary, but most radiology centers have prices between $150-250 dollars. In our opinion this test is well worth the money as it provides valuable information and serves as another layer of risk stratification.

If you are hesitant to start cholesterol medication, a CAC scan will go a long way in helping to sway your decision. If you are curious, ask your doctor about getting one.

Coronary Angiography:

Also called a Coronary CT angiogram, this is considered a “level up” from the CAC score. It is a type of CT scan done after a special dye in injected into your blood vessels. It provides a snapshot of the blood flow in your coronary arteries and can identify softer, non-calcified, plaques that may not show up on a Coronary Artery Calcium scan.

2. Change your diet

When it comes to using diet to improve your lipid panel, there are two main things to keep in mind. Research has consistently shown that decreasing your intake of processed and refined carbohydrates as well as decreasing your intake of saturated fats can result in lower LDL cholesterol. This includes foods like:

• Pasta
• Breakfast cereals
• Refined grains
• Processed meats like bacon and sausage
• Full fat dairy
• Fatty cuts of animal meats

Tip: A good way to replace your saturated fats with unsaturated fats is to change your cooking oil. For low heat, olive oil is an excellent choice. For higher heat, go with avocado oil. Avoid using vegetable and canola oils to cook if you can.

3. Can exercise improve cholesterol?

When it comes to exercise, the primary benefit to cholesterol is an increase in HDL cholesterol. Unfortunately, regular exercise does not move the needle much when it comes to LDL cholesterol. That said, regular exercise is one of the most important things we can do to reduce our risk of cardiovascular disease. If you are not a regular exerciser, you are missing out on tremendous benefits.

We highly recommend you head over to our Exercise section to learn about the different forms of exercise you can do to improve your health.

4. How About Stress?

While we cannot say for certain that stress and high cholesterol are directly linked, we can say that stress and high cholesterol are correlated. What this means is that stress plays an indirect role in the development of high cholesterol over time.  Those who are under high amounts of stress probably do not eat well and are more likely to be overweight. Both of these things increase the risk of high cholesterol.

Interesting Study on Stress:

There was a very small study published in 2021 that involved professional basketball coaches. The study looked at the effects of acute stress on a number of different markers, one of them being Apo(b) (a marker of cholesterol). What this study found was that immediately after an intense game, coaches had significantly increased Apo(B) levels. We are all exposed to stressors every day, so it is not a stretch to think that chronic stress can translate to chronically elevated cholesterol. That study can be found here if you are interested. Keep in mind it has not been peer reviewed yet.

5. Minimize Your Other Risk Factors

As we hope you can see by now, even if you have high cholesterol, you are not destined for heart disease. That said, there are actions you should take right away to minimize your risk. In order to help stave off heart disease, it is important to: