Introduction
We often think of cholesterol as something "negative" that we should worry about. Blood test results may spark a cycle of concern and mostly utter confusion as to how serious this is in the first place.
The truth is that cholesterol is more complex than we realise. In an effort to keep things simple, modern medicine reduced the issue to “good” and “bad” cholesterol. As with most things, and as you’ll explore in this blog, it is never that black or white.
High cholesterol is far more common than most realise. In the UK, roughly 4 in 10 adults aged 30 to 50 have elevated cholesterol, according to the British Heart Foundation. (1)
While high cholesterol is notorious for its link to cardiovascular disease—raising the risk of heart attacks and strokes—its role in metabolic health is often overlooked. Cholesterol is also a critical factor in metabolic syndrome, which increases the likelihood of developing diabetes, obesity, and other chronic conditions.
Factors such as genetics, diet, and lifestyle all play a role in cholesterol levels, making it essential to understand the facts before jumping to conclusions.
In this blog, "Cholesterol Explained”, I’ll be separating myth from fact to help empower you to make more intentional prevention and treatment choices.
Cholesterol Plays a Key Role in the Body
Cholesterol is a waxy, fat-like substance found in every cell of the body. It is absolutely vital for our existence! It plays a role in:
Cell Membrane Structure: Cholesterol is a crucial component of cell membranes, helping to maintain their fluidity and stability.
Hormone Production: It’s a precursor for synthesising steroid hormones like estrogen, testosterone, and cortisol.
Vitamin D Synthesis: Cholesterol is needed to produce vitamin D when the skin is exposed to sunlight.
Bile Acid Formation: It helps in the production of bile acids, which are necessary for digesting fats.
While cholesterol is necessary for all of these functions, there are instances where it becomes problematic, as we’ll explore further on in the blog.
Myth: All cholesterol is bad and should be avoided.
Bust: Cholesterol is essential for numerous bodily functions, including hormone production, vitamin D synthesis, and cell membrane integrity.
How Cholesterol Changes as We Age
Having high cholesterol starts to become more prevalent in mid-life. According to the NIH, total cholesterol levels steadily increase with age from 20 to 65, following which they decrease slightly in men and tend to plateau in women. (2)
A variety of modifiable risk factors (i.e. factors we have "some" control over) are behind this phenomenon, including:
Metabolism Changes: They may lead the liver to become less effective at clearing LDL cholesterol. You can proactively maintain metabolic health using nutrition and lifestyle.
Telomere shortening: As we age, telomeres around our DNA shorten, causing cells to lose their ability to reproduce properly, including cholesterol modulating liver cells. You can reduce the rate of telomere shortening and protect your DNA using diet and lifestyle.
Myth: High cholesterol is a normal part of ageing and can't be controlled.
Bust: While cholesterol levels can naturally rise with age, lifestyle changes, and dietary adjustments can still significantly manage and lower cholesterol levels.
When Does Cholesterol Become an Issue
The two key players in the topic of cholesterol are High-Density Lipoprotein (HDL) and Low-Density Lipoprotein (LDL), are often hailed as the “good” and “bad” cholesterol, respectively.
This over-simplification has led to wide misconception around the topic. Before we pass judgement, let’s dive into the scientific meaning of these terms.
Because cholesterol is not water soluble, it must be carried around the bloodstream in special vehicles called lipoproteins. As the name suggests, lipoproteins are composed of lipids and proteins. LDLs will have a higher share of lipids compared to proteins, whereas HDLs carry more protein.
As the particles are shuttled around our body in blood vessels, they brush up against the vessel wall lining, the endothelium. HDL can easily cross the endothelial barrier in both directions. Whereas, LDL often gets stuck, which over time creates a “fatty streak” inside the artery.
As this streak becomes oxidized over time, you end up with atherosclerosis, a.k.a. plaque build-up in the arteries, a major marker for heart disease.
One of the main reasons that HDL is dubbed the “good cholesterol” is because it has the ability to go to fatty streaks and mop up the cholesterol back out of there, thus reducing the speed of plaque build-up.(3)
Moreover, each of these lipoproteins is wrapped with one or more larger molecules called apolipoproteins which provide a sturdier structure.
HDL is wrapped with apolipoprotein A (or apoA) and particles like LDL, IDL (intermediate density), and VLDL (very low density) with apolipoprotein B (or apoB).
According to the work and research of Dr. Peter Attia, the author of the Outlive, it is not the cholesterol which causes the issue, it is the nature of the particle that carries it.
According to Dr. Attia, ApoB particles have the potential to deliver cholesterol into an artery wall, the problem we’re trying to avoid, and 90-95% of the ApoB particles are LDL particles.
He states that the lipoprotein that contributes to atherosclerosis carries an ApoB signature, i.e. found on LDL, IDL and VLDL particles.
LDL is thus "bad" but there are more baddies too like IDL and VLDL.
PS: High levels of LDL may not always be a cause for concern. High levels of HDL may not always be protective if other risk factors are present.
Context matters! Read on to find out more.
Myth: HDL is the “good cholesterol” and LDL is the “bad cholesterol”.
Bust: The particle type and number matters more than the cholesterol contained within.
Inflammation & Oxidative Stress Drive Heart Disease
Oxidative stress is defined as having an excess of "free radicals" compared to antioxidants in the body.
Oxidative stress can oxidise LDL cholesterol particles, making them more harmful. Oxidised LDL is more likely to penetrate artery walls and contribute to plaque formation.
Inflammation, a natural immune response to damage in the body, sends signals commanding white blood cells to go to specific areas. That is its normal function. Issues arise when inflammation becomes chronic.
As the plaque continues to form, immune cells are sent to the site triggering inflammation in the artery walls.
Low levels of inflammation irritate the blood vessel lining and may further promote the growth of plaques, or worse might loosen plaque into the arteries and trigger blood clots, the primary cause of strokes (blood clot in the brain) and heart attacks (blood clot in the heart).
Inflammation doesn’t just respond to plaque—it accelerates its formation and increases the likelihood of a cardiovascular event.
Leading an anti-inflammatory, anti-oxidant rich lifestyle thus becomes ever more critical. The key factors that tame inflammation and offset oxidative stress are:
Quitting smoking
Limiting alcohol
Balancing blood sugar levels
Eating antioxidant-rich, anti-inflammatory foods
Exercising regularly
Keeping stress in check
Myth: Heart disease is primarily caused by high cholesterol alone.
Bust: While high cholesterol is a risk factor, inflammation and oxidative stress play significant roles in the development of heart disease, heart attack, or stroke. Addressing these factors through diet and lifestyle is crucial for comprehensive heart health.
Cholesterol is Critical for Metabolic Health
Cholesterol is more than just a marker for heart disease; it plays a critical role in overall metabolic health. The balance between "good" HDL cholesterol and "bad" LDL cholesterol can influence metabolic processes significantly.
Poor metabolic health – characterised by insulin resistance, obesity, and chronic inflammation – can disrupt cholesterol metabolism, leading to higher levels of LDL and triglycerides, while lowering protective HDL.
This unhealthy balance creates a vicious cycle, as elevated LDL and low HDL further fuel metabolic dysfunction, increasing the risk Type 2 diabetes, Non-Alcoholic Fatty Liver Disease (NAFLD), hypertension, and more.
Addressing cholesterol is, therefore, a key step in improving metabolic health, a specific area of interest for me. Conversely, ensuring good metabolic health protects us from cardiovascular diseases, and is a better measure of health than looking at cholesterol alone.
Myth: Cholesterol only affects heart health.
Bust: While cholesterol is well-known for its role in cardiovascular disease, it also plays a significant part in metabolic health. High cholesterol is a key indicator of metabolic syndrome, a cluster of conditions that increases risk of diabetes, NAFLD, hypertension, and other chronic diseases.
Testing: Making Sense of the Numbers
In a standard blood test, called a lipid panel, you get an insight into Total Cholesterol, LDL, and HDL, all measured in mg/dL. Anything outside of the reference range gets flagged.
If the total cholesterol is above 200 mg/dL, your cholesterol will be flagged as high. The reference range for LDL is 100 mg/dL at the upper end and for HDL is 40mg/dL at the lower end.
There is a difference between reference ranges (which are based on the tested population), and optimal ranges (based on what is ideal for good health).
Optimally, you will want total cholesterol to be less than 170 mg/dL, LDL to be as low as possible and certainly less than 70mg/dL, and HDL to be at least more than 50mg/dL for men and 60mg/dL for women.4
Another great metric is Total Cholesterol/HDL ratio, which optimally should be below 3.
However, the oversimplified approach of focusing solely on HDL and LDL levels in standard cholesterol tests has limitations.
Many people are walking around with high LDL but are actually at lower risk, while others have a lower LDL but are still at risk.
In fact, in the US, 50% of people with heart disease have normal traditional lipid values. To determine how “bad” the LDL is, you need to dig deeper.
Measuring cholesterol in the standard way provides insight into the total cholesterol mass (a.k.a. passengers), but nothing about the number or the size of particles (a.k.a. the buses carrying them).
Larger particles, akin to double decker buses, move in an "orderly fashion" through the bloodstream. In contrast, smaller particles, akin to mini-buses cause trouble by "zig zagging" through.
Smaller particles are more dangerous as they lodge into arterial walls, gradually building up and constricting arteries over time. As they lodge into arterial walls these particles begin to oxidise, forming plaques that increases cardiovascular incidence risk.
Therefore, the higher the number of smaller LDL particles in your bloodstream, the more the cardiovascular risk you carry.
So, how can you find out more about your cholesterol profile? Two advanced testing mechanisms are becoming more prevalent:
Advanced Lipid Blood Tests: Measures the type of apolipoprotein particles present in the blood, with a focus on ApoB, which is a marker for the prevalence of higher risk particles like LDL, IDL, and VLDL.
Nuclear Magnetic Resonance Tests: Unlike a regular cholesterol test, which measures the amount of cholesterol within LDL particles, the NMR test counts the actual number of LDL particles (LDL-P).
NMR also measures the size of LDL particles, which can be either small and dense or large and buoyant.
Small, dense LDL particles are more likely to penetrate artery walls, become oxidised, and contribute to plaque formation, making them more atherogenic (plaque-causing). Larger particles are less harmful.
For people who are at higher risk of cardiovascular disease, considering advanced cholesterol testing could be an option to discuss with your doctor. Many of these diagnostics are now available direct to consumer, using private medical healthcare.
Myth: High total cholesterol or LDL levels on a blood test is a certain indicator for cardiovascular risk.
Bust: Total cholesterol and LDL alone do not form a complete picture. It’s essential to understand the type, number and size of particles to get an accurate assessment of cardiovascular risk.
The Truth About Statins
Statins are a class of medications commonly prescribed to lower low-density lipoprotein (LDL) cholesterol levels in the blood. They are particularly helpful for people who have historically had a cardiovascular incident, or who have a family history of heart disease.
The global statin market is estimated to rise to $20B by 2032.(5)
Statins are the number one drug on the market, because when prescribed, statins are often taken for life! They work by inhibiting the enzyme HMG-CoA reductase, crucial for cholesterol production in the liver.
While statins have been shown to significantly decrease the risk of cardiovascular events, particularly in individuals with a history of heart disease or high LDL levels, their efficacy in lower-risk populations is more controversial.
Critics argue that the benefits may be overstated, especially given the potential side effects, which can include muscle pain, fatigue, and an increased risk of diabetes.
My main concern with statins, is that people who are on them feel a “false sense of security” and gold standard protection from cardiovascular disease.
They often do not change their habits and lifestyle to support their wellbeing, which leaves root-cause inflammation, oxidative stress, high blood pressure, high blood glucose unaddressed.
By relying solely on medication, many patients today are missing out on an opportunity to address the modifiable risk factors that increase the risk of a cardiovascular event.
Lifestyle changes and dietary adjustments should be considered as necessary complementary therapies to statin prescriptions.
For younger people with elevated cholesterol levels, nutrition and lifestyle change can absolutely turn the ship around, reducing the burden of lifelong medication.
Myth: Statins are the best and only solution for managing high cholesterol.
Bust: While statins can be effective, they are not without side effects and are not the only option. Nutrition and lifestyle interventions play a big role in addressing root cause issues and reducing the burden of lifelong medication.
We Need to Talk About Eggs!
A common misconception about cholesterol is that it is somehow triggered by the cholesterol we get from our food. In 1968, a paper by the American Heart Association singled out eggs as a heart disease causing food, and ever since then, the humble egg’s reputation never fully recovered.
The unfortunate repercussions are that people steered away from eggs towards high-carb, high fat breakfasts like cereals, toast, and pastries.
Studies have since shown that most of the dietary cholesterol we consume, i.e. cholesterol from food, ends up being excreted, not absorbed.
The cholesterol in our system is in fact mostly produced by the liver.(6)
For most people, the amount of cholesterol eaten has only a modest impact on the amount of cholesterol circulating in the blood.(7) However, a minority of people are hyper-responders, meaning that their serum cholesterol rises with increased dietary cholesterol consumption. The only way to find out is by trial and error.
The grey area created by hyper-responders has meant that eggs are known as “nature’s multivitamin”, are sometimes avoided completely!
When indeed eggs have a unique combination of essential nutrients like protein, vitamins (A, D, E, K & B12), minerals (iron, selenium), antioxidants (lutein, zeaxanthin), and choline (important for brain health) that is a hard combination to match in any other singular food. So, please don’t completely write them off just yet!
Myth: Eating eggs significantly raises cholesterol levels and increases heart disease risk.
Bust: Recent research suggests that dietary cholesterol from eggs has a far less of an effect on blood cholesterol levels, for most people, than originally assumed. Eggs can certainly be part of a healthy diet.
The Optimal Diet to Manage High Cholesterol
Besides eggs, saturated fats from products like butter, hard cheeses, fatty meats, fatty poultry, palm oil and even coconut oil have also been "vilified". Where the reality is that saturated fats are not all created equal.
Some fats do raise cholesterol, whereas others lower cholesterol. The fat in coconut is very from the fat in mass farmed beef.
My view is that quality saturated fats like grass-fed butter, grass-fed beef, free range poultry and coconut oil can absolutely be part of a balanced diet. One just needs to be mindful of the quantities.
The less-talked about culprit when it comes to heart disease is: sugar!
One recent study published in JAMA Internal Medicine found that those with the highest sugar intake had a four-fold increase in their risk of heart attacks compared to those with the lowest intakes.(8)
Among its many problems, sugar contributes to inflammation, the root of heart disease incidents. It also directly increases LDL cholesterol, and lowers HDL cholesterol, and increases the level of triglycerides, as any excess glucose not used immediately gets cleverly stored as fat for later.
The optimal diet for cardiometabolic health in general balances out macro and micro-nutrients to improve metabolic function and reduce inflammation in the body, thus reducing risk of heart disease.
At a high level, here are the components of an optimal nutrition approach for cholesterol management:
Focus on whole, minimally processed foods
Swap out refined carbs like white bread, rice, and pasta for complex carbs like whole grains and starchy vegetables
Increase your intake of fiber-rich foods like vegetables, beans, and legumes
Consume more Omega 3 like oily fish, chia, flaxseed and more mono-unsaturated fatty acids (MUFAs) like avocados and extra virgin olive oil, nuts
Moderate your saturated fat intake, focus on high-quality limited quantity
Consume quality protein to support satiety, and contribute to muscle synthesis
Myth: Only medication can effectively reduce cardiovascular risk.
Bust: Nutrition and lifestyle changes, such as adopting a heart-healthy diet, increasing physical activity, and managing stress, can dramatically lower cardiovascular risk and improve overall heart health.
The Role Genetics Plays in Cholesterol
While genetics do play a role in influencing cholesterol levels, they are only part of the picture.
Approximately 1 in 250 people worldwide suffer from familial hypercholesterolemia (FH), a genetic condition affecting the LDL receptor function, that leads to very high cholesterol levels and increases the risk of heart disease.
However, the FH condition constitutes only 2-5% of the high cholesterol cases.(9)
The vast majority of people with high cholesterol (~95-98%) have the condition due to lifestyle factors, such as poor diet, lack of exercise, or other health conditions like obesity or metabolic syndrome.
While genetics play a role, often diet and lifestyle trigger the condition.
Some genetic single nucleotide polymorphisms (SNPs) pronounced 'snip', are pre-wired mutation that may pre-dispose a person to certain metabolic conditions. The expression of these genes is modulated by diet and lifestyle.
The science of epigenetics looks at how diet and lifestyle habits influence gene expression.
Even though one may have a specific genetic mutation, their daily habits can reduce the expression of the gene. The converse is true. You may be blessed with the best genes, but your habits and lifestyle, can damage your DNA expression and lead to chronic disease.
Nutrigenomic tests looking at the genes involved in metabolic function can be a helpful insight into personalised nutrition and lifestyle approach to help support SNPs in the best way possible.
Here are some example genes that play a role in high cholesterol conditions, and the nutrition factors that play a role in inhibiting or expressing the gene:
LDLR: LDL receptors enable uptake of cholesterol by the liver, which removes about 70% of LDL from the bloodstream. LDLRs therefore have an essential role in LDL regulation. A SNP in the LDLR gene can lead to conditions like FH described earlier.
Nutrition modulators: Polyphenols in red grape skin, berberine, and omega-3 fatty acids can increase LDLR sensitivity. High fructose intake can increase the risk of glycation which negatively impacts LDLR.
CYP7A1: Cholesterol is converted to bile acids via this gene. Bile acids are needed to absorb and digest fats in the small intestine. This is also the primary mechanism for removing cholesterol from the body. A SNP on CYP7A1 lowers its activity, leading to a slower conversion to bile acids, and therefore, higher cholesterol levels.
Nutrition modulators: Oats, taurine, green tea can support CYP7A1 activity and help remove cholesterol.
UCP1: A SNP on UCP1 is associated with impaired energy metabolism and lower resting metabolic rate. This can promote fat storage, increased BMI and obesity. It is also associated with high triglycerides, high LDL and low HDL.
Nutrition modulators: Nucleotides (found in high fructose corn syrup, seafood, organ meat and alcohol inhibit UCP1, whereas omega 3 fatty acids activate it.
Myth: Genetics are the sole determinant of your cholesterol levels and cardiovascular risk.
Bust: While genetics play a role, lifestyle factors such as diet, exercise, and overall health can significantly influence cholesterol levels and cardiovascular risk. Genetic predisposition can often be better manifested with lifestyle changes.
Conclusion
Cholesterol is an intricate and multifaceted topic. Understanding the role of cholesterol in both heart and metabolic health is essential for taking control of your well-being.
While it’s often misunderstood, cholesterol is more than just a number on a blood test—it’s a crucial factor in how your body functions.
By separating myth from fact, we can see that while high cholesterol is a risk factor for heart disease, its relationship with metabolic health, particularly insulin resistance and type 2 diabetes, is just as significant.
Taking proactive steps to testing and then managing your cholesterol levels, such as adjusting your diet, increasing physical activity, managing stress, and possibly considering medication when necessary, can not only reduce your risk of cardiovascular diseases but also improve overall metabolic function.
The key lies in understanding your unique risk factors, staying informed, and working with healthcare professionals to interpret your results holistically.
By doing so, you can actively improve your metabolic health and reduce your long-term risk of chronic diseases.
More About Nada
As a Certified Metabolic Health Coach, I focus on helping my clients achieve lasting health by restoring metabolic balance to sustain energy levels throughout the day, burn fat effectively, and build muscle over time.
These metabolic health benefits are the foundations of lasting wellness, because a healthy metabolism slashes your risk of chronic illnesses like diabetes, cancer, dementia, and cardiovascular diseases down the line.
Your 30s and 40s are when you can more easily lay the foundations of long-term health and longevity. Don’t wait until your 50 or 60 to start taking action – it will be much harder then!
I want to make early mid-life a chapter in which you can feel reassured about their health and thrive in all aspects of their life.
Previously, a Partner in a top-tier strategy consulting firm, I pivoted into health coaching and founded The Healthy Chain, after a personal experience with ovarian cancer, which prompted me to make health my top priority.
I am a mum of three and I know how hard it can be to prioritise health when you are juggling a career and family. I focus on realistic tweaks and swaps that slot easily into busy schedules.
You can now schedule a free "Discovery Call" with me to explore how you can start on your journey towards better health. Use this link to book.
Get in touch – I love hearing from you!
Thank you,
Nada Soubra
References
Comments