The truth – and therefore the real risk – is more complicated than you think

There is not just one type of cholesterol; there are many.  Some are good; some are bad.  Knowing which is which – and which lifestyle choices promote the good and dilute the bad – is crucial to our ability to dodge mankind’s number one killer, heart disease.

Andy is a 53-year-old gentleman who attended The Vitality Clinic with high cholesterol.  He was worried that he might suffer a heart attack.  Andy has had high blood pressure (BP) since 2010, well controlled with a single BP pill.  Despite this, he was diagnosed with gout, and BP progressed to chronic kidney disease in 2014, for which he received no treatment.

A routine blood test in 2016 revealed high cholesterol and triglycerides.  Andy was prescribed a statin, a cholesterol pill, which gave him painful leg muscles and weakness, and he had to stop taking it as he could not walk.

Andy then sustained head and neck injuries during an assault at work.  His blood pressure subsequently went out of control, despite multiple BP pills.  He experiences visual hallucinations when his BP goes too high.  Andy progressed to end-stage kidney failure, treated with peritoneal dialysis, run every night at home.

Andy was overweight (BMI 27.5), with a waist-hip ratio of 0.97, suggesting excess belly fat.  His BP was high at 161/98, despite multiple BP medications.  His liver was enlarged (a sign of fatty liver).

The overall diagnosis was a metabolic syndrome, evidenced by belly fat, high BP and high cholesterol.  High BP was complicated by kidney failure, requiring dialysis.  Despite the key diagnosis of kidney failure, Andy was fixated on his high cholesterol.  He was worried this was going to give him a heart attack!

In this blog, you will discover whether Andy’s high cholesterol is a real danger and if he needs to take action to lower his risk.  We will explore which types of cholesterol may escalate Andy’s risk.  And finally, discuss what we can do to contain this time bomb and lower our chances of encountering the number one killer, heart disease.

A heart attack is a combination of chronic progressive vascular disease and a blood clot.  Cholesterol plaques (atherosclerosis) build up over many years or decades, reducing the artery lumen and blood flow, resulting in effort-related chest pain or angina.  However, the acute component is the formation of a blood clot, which causes complete blockage and a heart attack.

Andy’s blood tests showed a high total cholesterol at 9.0, with a high LDL (bad guy) at 6.15 but a normal HDL (good guy) at 1.90.  You would expect high LDL and normal protective HDL buffers.  But is there any other factor that may influence Andy’s risk of a heart attack?

Let’s learn about the cholesterol family members

The family exists because fat does not dissolve in water and, therefore, cannot be transported in blood.  It is loaded onto particles (vehicles) of different sizes, known as lipoproteins.  The particle size decreases, and the density increases consecutively in the following cholesterol particles.

  • Chylomicrons are large particles that carry dietary fat (triglycerides (TG)) absorbed from the gut after a fatty meal and deliver the TG load to the liver.
  • VLDL (very low-density lipoprotein) particles carry fat (triglyceride) made in the liver, delivering part of their triglyceride load to cells. VLDL turns into intermediate-density lipoprotein (IDL), and further delivery of triglycerides makes them LDL (low-density lipoprotein.)
  • LDL particles contain more cholesterol than triglycerides.  They are the smallest particles and can cross the vascular endothelium (lining) to form plaques. They deliver cholesterol from the liver to the tissues.
  • HDL (high-density lipoprotein) works in the opposite direction, collecting damaged (oxidised) LDL to be cleaned up in the liver.

Andy’s very high total and LDL cholesterol does not mean he will have a heart attack.  A large meta-analysis of patients admitted with a heart attack to over 500 hospitals revealed that none had high cholesterol, 75% had normal LDL cholesterol, and 50% had optimal LDL cholesterol!

This ground-breaking research prompted the US dietary guidelines advisory committee to lift a 6-decade low-fat diet recommendation, reassuring the public not to worry about dietary cholesterol, which was classified as “a nutrient of no concern.”

“Lucky to have a normal level of the protective HDL”

Another study found that 90% of patients who suffered a heart attack had a low HDL.  This makes a low level of the protector HDL the real driver of heart attacks.  The total cholesterol and HDL ratio is a better tool to assess the risk of a heart attack than LDL levels.  Andy had a normal ratio of 4.7.

The standard lipid profile was reassuring but did not answer Andy’s question accurately.  Since the quantity of cholesterol does not seem to influence cardiac risk, further tests revealed more interesting findings about the quality of the LDL particles.

Think of lipoprotein particles (LDL-P) as cars that carry LDL cholesterol (LDL-C) as passengers.  The standard lipid profile measures the passengers whilst ignoring the cars!  However, cars (LDL-P) can damage the arterial lining and initiate plaque formation.  More cars on the road increase the likelihood of accidents, i.e. the increased risk of heart disease.

Therefore LDL-P is more accurate in predicting the risk of heart disease than LDL-C.  LDL particles are either large, fluffy, healthy beachballs or small, dense golf balls.  The latter is heavy and can stick together to initiate the formation of clots.  This could result in an acute vascular event, such as a heart attack or stroke.

You can measure LDL particles directly or via the surrogate marker Apo B.  Andy’s advanced lipid profile revealed a very high LDL particle number of 2350 (normal is less than 1000), mostly of the dense golf balls, and a high Apo B at 1.87.

A study of over 300 men found a strong association between LDL particles and metabolic syndrome (belly fat, high blood pressure, high blood sugar, high triglyceride, low HDL.)

High triglyceride substantially increases the risk of heart disease. It is a common feature of metabolic dysfunction–in obese and overweight people, diabetics, and those (like Andy) suffering from chronic kidney failure.

Despite having normal protective LDL, Andy was in big trouble and had a high risk of heart disease.  The advanced lipid profile revealed multiple risk factors.  These included low-grade inflammation, high oxidative stress and atherogenic (clot-forming) cholesterol particles that included LDL-P and a high Lp(a) cholesterol.

Where should our preventive focus lie?

Vascular disease is basically a combination of three processes.  It starts with chronic low-grade inflammation of the arterial wall, secondly, oxidative stress that damages (oxidises) the third component, LDL (bad) cholesterol.

Chronic low-grade inflammation damages the arterial wall lining, causing cracks that allow the oxidised LDL to sneak in to initiate plaque formation.  Gaining access to the artery wall, the oxidised LDL is attacked by immune cells (macrophages) to make foam cells that continue to grow to form an atherosclerotic plaque.

Andy’s tests showed high inflammation markers and extremely raised high sensitivity CRP (hs-CRP) at 6.00 (more than 6 times the normal limit.)  Homocysteine is another inflammatory marker, and a vascular and neurotoxin was high at 24 (3 times the normal limit.)

Andy admitted to consuming a diet high in sugar and processed carbohydrates, including bread, white rice, pasta, and pizza.  Refined carbs are digested into sugar, raising the blood glucose level, and causing chronic low-grade inflammation and high levels of oxidative stress, two components of vascular disease.

Trans-fatty acids in French fries, doughnuts, and cookies, increase your total and LDL (bad guy) but lower the protective HDL (good guy).  It also increases levels of triglyceride and lipoprotein (a) levels.  Trans fat promotes atherosclerosis by driving inflammation and oxidative stress, making the person in line for heart disease.

If you want to prevent heart disease, then you must target the big elephants in the room!

There is solid evidence that today’s obesity, high cholesterol, and heart disease pandemic is triggered by high fructose corn syrup (HFCS) in fizzy and non-fizzy drinks, juices, cookies, sweets, and its addition to processed foods, including bread.  HFCS is produced from corn through a chemical process.  Unlike fruit sugar, fructose is not associated with fibre or nutrients.

When ingested in large amounts, HFCS turns the liver into a fat-producing factory, which usually results in fatty liver.  The liver transports excess fat into the body via lipoprotein vehicles making those very dangerous small LDL particles; it increases your triglycerides and lowers your protective HDL.

It is the perfect storm for heart disease and heart attack.

Foods that lower cholesterol

Let’s deal with the bad stuff first.  Red meat should be limited to 100 grams daily, but not every day.  Processed meat, such as burgers and sausages, are high in saturated fat.  The frying makes energy-dense food (from fat in the oil plus the calorie content of the food.)  And sugar and high carbs, such as pastries, cookies, pasta, and pizza, are also bad.

Eat plenty of fruits and vegetables, avocados, nuts and seeds, and oily fish like mackerel, herrings, and salmon.  Regular exercise also increases the protective HDL and lowers the oxidised LDL.

In view of his high cardiovascular risk, we made Andy aware of the need for urgent tests to assess his current cardiovascular health status.  These tests included a CT calcium score, which basically measures the amount of calcium deposited in the coronary arteries – the higher the score, the higher the cardiac risk.  A carotid Doppler scan examined the degree of occlusion of the carotid arteries, the primary suppliers of the brain.  The percentage of oxidised (damaged) LDL predicts the progress of the disease.  And depending on the results, Andy may require a cardiology intervention to abort an impending heart attack.

Besides specialist invasive procedures, Andy may need to take a small dose of the cholesterol pill statin and make extensive lifestyle changes.  These may include a healthy diet, restful sleep, good physical activity, low-stress levels, and loving relationships.  He also needs potent supplements to lower inflammation, oxidative stress, and LDL levels.

Despite the high risk discovered in Andy’s results, he felt reassured and more receptive to attending the cardiology department to deal with the immediate danger and work long-term to reverse the serious risk factors.  He took drastic measures to control his BP tightly and continues daily home peritoneal dialysis.

Statins are indeed the most effective treatment to lower LDL and total cholesterol but at a very high cost.  The most common side effects are muscle and liver damage, diabetes, and dementia.

So, my friends, you can see that ‘cholesterol’ as a whole is not simply bad, that a low level of the good guy (HDL) is far worse than a high level of the bad guy (LDL), and that the small, dense particles are the ones that stick in the arteries and cause heart attack and stroke.  But, as always, the lifestyle solutions are simple and within everyone’s grasp!

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