Marks Daily Apple
Serving up health and fitness insights (daily, of course) with a side of irreverence.
30 Jan

The Definitive Guide to Cholesterol

That makes it easy.

With all the talk of fighting, battling, combating and beating cholesterol into submission, you’d think it had a black plastic body suit and James Earl Jones’ voice. Big Pharma has, dutifully created quite an arsenal for our supposed defense, and the medical community has been a willing faction, delivering the rhetoric that would incite us all to pick up arms. Now if only we could put down the Big Macs. And the Ding Dongs, HoHos, Twinkies and…you get the point.


But the insidious rogue, that menacing villain isn’t to be found at the helm of the Death Star. Turns out, there is an enemy within and it’s not even cholesterol. Before you fall to your knees, rip your shirt and gnash your teeth, you might want to consider news you don’t hear often enough: the much aligned compound in question is absolutely essential to your physical, psychological and cognitive functioning.

Yes, the message these days seems to be that no number is too low when it comes to cholesterol (except HDL but we’ll get to that later). I’d like to offer a deeper look into the issue, user-friendly enough but more complex and contentious than you’ll get from the commercial sound bytes telling you to talk to your doctor about blah, blah, blah. Consider it one of MDA’s definitive guides that we’re happy to serve up for our gregarious and always thoughtful community.

Excuse me, have you met cholesterol?


Cholesterol is a waxy, charming lipid gracing every cell’s membrane and our blood plasma. Its jobs, which are many, include insulating neurons, building and maintaining cellular membranes, metabolizing fat soluble vitamins, producing bile, and kick-starting the body’s synthesis of many hormones, including the sex hormones. Cool stuff actually.

Given all the work cholesterol has to do, the liver is careful to ensure the body always has enough, producing some 1000-1400 milligrams of it each day. In comparison, the 300 milligram recommended limit for dietary cholesterol (your tax dollars at work in the USDA) is a drop in the bucket. And get this: our livers come with feedback mechanisms (at no additional cost) that regulate cholesterol production in response to our dietary intake. When we eat more, it makes less, and vice-versa. Imagine that!

(Interesting note: While animal products like meat, eggs and dairy, are far and away the primary source of dietary cholesterol, plants contain trace amounts of cholesterol and cholesterol-like substances called phytosterols, which may help lower blood or “serum” cholesterol. Not that that matters, as we shall soon see.

So, what’s with all the acronyms on my cholesterol profile, you ask. Let’s take a look. First, there are high density lipoproteins (HDL). (Lipoproteins are spherical fat particles with water-soluble proteins around their exterior. They transport cholesterol). HDL: everybody loves this guy. He has the popular job of transferring cholesterol from the body’s tissues back to the liver. It’s basically the end of the line with this route, and the liver then excretes it through bile. HDL is the one to naturally help get rid of excess cholesterol when the body’s done with it, hence his universal popularity. Some cholesterologists (just made that up) even refer to him as Nature’s garbage truck.

Next, there are low density lipoproteins, LDL. LDL is a lipoprotein and delivery man as well. He has the disgraced job of transporting cholesterol after production from the liver to the body’s tissues. Remember, this is an important job! That cholesterol has a honey-do list a mile long.

Ironically, it turns out that it’s not the cholesterol part of the LDL or HDL moiety that is dangerous, but the actual lipoprotein part. Unfortunately, once medicine had found a way to differentiate between the amount of HDL and LDL in a cost-effective blood test, it was the cholesterol part that got the short end of the deal.

The latest research into LDL shows that there are actually sub-categories of this cholesterol transporter and that some are more dangerous than others. The larger, more billowy LDL particles are now thought to have little or no significant role in heart disease. On the other hand, the smaller, dense LDL particles are the ones believed to be most involved in the process of inflammation that begins the atherosclerosis cascade. And wouldn’t you know it, but it’s a diet high in simple carbs that most readily promotes the formation of these small LDL particles! Unfortunately, this important distinction is probably something your doctor knows very little about, yet it’s the number of small particle LDL that might be the most important reading in any cholesterol test. So a total cholesterol of, say, 230 or even 250 might not be dangerous at all if your HDL is high and your small particle LDL is low.

Before we move on, let’s give brief mention to triglycerides. Triglycerides are essentially the form that fat takes as it travels to the body’s tissues through the bloodstream. The relationship between triglycerides and cholesterol is more of an association. A high triglyceride level, which is unequivocally fueled by a high carb diet, is very often a marker for other problems in the body, particularly insulin resistance (and accompanying risk of diabetes) as well as inflammation (with its risk of heart disease). High levels are often seen with low HDL cholesterol. Once again, the high carb diet wreaks havoc.

The Rise of Cholesterol Panic

Cholesterol free zone looks to have a mascot.

Heart disease took off in the early part of the twentieth century, and doctors frantically searched for the cause throughout the next several decades. Tests in the fifties initially showed an association between early death by heart disease and fat deposits and lesions along artery walls. Because cholesterol was found to be present in those deposits (of course it would!) and because researchers had previously associated familial hypercholesterolaemia (hereditary high blood cholesterol) with heart disease, they concluded that cholesterol must be the culprit. In fact, what happens is that in response to an inflammatory situation, the body uses cholesterol as a “band-aid” to temporarily cover any lesions in the arterial wall. In the event the inflammation is resolved, the band-aid goes away and repair takes place. No harm, no foul. Unfortunately, in most cases, the inflammation proceeds, the cholesterol plaque is eventually acted on by macrophages and is oxidized to a point at which it takes up more space in the artery, slows arterial flow and eventually can break loose to form a clot. And all this time the cholesterol was just trying to be the good guy! Blaming cholesterol for all this is like blaming a cut finger on all the band-aids you have lying around your house.

Death from heart disease, according to the CDC, has declined over 50% since its peak in the 1950s. The success is attributed to a number of factors, including a decrease in smoking and better diagnosis and treatment of high blood pressure. Included in the list of factors was the opportunity for public education regarding the scientific findings/theories related to cholesterol; however, measures (including CDC estimates) of dietary saturated fat intake show that intake has generally stayed the same or risen.

But the dietary cholesterol message stuck.

Big Pharma To The Rescue!
Early drugs that “battled” high cholesterol prevented its absorption in the digestive tract. The side effects on the digestive system were unpleasant enough and the results modest enough that the drugs never garnered much support from either side of the prescription pad. Enter statins. Statins inhibited the natural production of cholesterol. Side effects were not as immediately noticeable or uncomfortable, and the results were quite good (at least at lowering cholesterol). (The recently beleaguered Vytorin and Zetia combined statin actions with a substance that reduces absorption of dietary cholesterol, preventing your body from trying to compensate for the lower natural cholesterol production.)

But what about the body’s natural impetus to produce a given and necessary amount of cholesterol? What happens to the parts of the body that need the cholesterol? What about the liver’s regulating mechanism? What happens when you mess with evolution? Exactly. Those are the sorts of questions that get thrown aside when you’re riding Big Pharma’s cholesterol hobby horse.

What Are the Problems With This (“Lipid”) Model?

Million Dollar Question

Oh, boy. There’s the million dollar question.

First off, let’s go back to the evolutionary question. As a naturally self-regulating system, the body will react if it doesn’t have enough cholesterol (yes, the body’s definition of enough and not Merck’s). If there’s not enough cholesterol, the alarm goes off, strobe lights flash and the body goes into crisis mode. Corticoid hormones coordinate a redistribution of cholesterol, a triage of sorts in which cholesterol is rationed among the many areas of the body that need it. Nonetheless, the body is now working under hardship conditions.

Adequate cholesterol isn’t available for the body’s repair system, for the uptake of serotonin, for the full initiation of Vitamin D and hormone production and their regulation of blood sugar and inflammation, etc., etc. What does your logic tell you here? Yup, nothing is running the way it should.

Let me also add that everyone’s cholesterol profile is going to be different, no matter what. And I acknowledge that a very small percentage of people out there genuinely have *true* hereditary high blood cholesterol, familial hypercholesterolemia, a metabolic condition with impaired or even lack of ability to metabolize cholesterol. This condition can have serious health consequences. By the way, this condition, in its heterozygous form affects at most 1 in 500 people. Total serum cholesterol in these folks is in the 400 mg/dl range (as opposed to the 200 recommended). The homozygous form affects about 1 in 250,000. You likely don’t know anyone in this category because their disorder almost always ends their lives at a very young age.

I mention familial hypercholesterolemia because I want to distinguish it from the claim made by Big Pharma ads that you may have higher cholesterol because people in your family did, and – can you believe it – their company is here to help. Duh! Everyone’s family influences cholesterol profiles. It’s, in small part, genetic. No big worry there. Just because you come from a family with “elevated” cholesterol doesn’t mean you have the familial hypercholesterolemia metabolic disorder. You can pretty much bet a whole lot o’ money on the likelihood that your cholesterol profile – good or bad – has more to do with learned behaviors like diet and exercise. “Elevated” cholesterol doesn’t equate with metabolic disorder.

Officer, You Got the Wrong Guy!
I’ve said it before, and I’ll say it again. Sound and reliable medical research hasn’t proven that lowering (or low) cholesterol in and of itself reduces risk of death from heart disease across a population. Yes, there is always that single isolated guy who throws off the curve, but he (or she) is a statistical anomaly and doesn’t negate the legitimacy of the model. For instance, the Japanese people of Okinawa are among the healthiest in the world. Their heart disease rate is extremely low, but they tend to have “elevated” cholesterol levels.

The fact is, half of all first time heart attack sufferers have a perfectly “normal” cholesterol profile. What does this tell you? There must be some other piece here behind the “other half” and, I would solidly argue, behind the first half. Cholesterol is a red herring.

It all boils down to inflammation. Inflammation is the number one factor in heart disease. This is an accepted fact now, but it still gets little attention and no real prevention or treatment. Think about it: you have your cholesterol levels checked every five years or more if your profile is “problematic.” When do you have biomarkers for inflammation checked? Unless you’ve had a heart attack or been diagnosed with a serious medical condition, probably never.

Fighting inflammation near and far...

Inflammation. What is it caused by? Not fat, but carbohydrates. Yes, sugars and processed carbs are highest on the list of perpetrators here, but grains and starches as a whole contribute to the problem. LDL rises directly not with the amount of saturated fat you eat but with rising levels of inflammation caused by carbs and trans fats.

Oxidation. Furthermore, nearly every study suggests that LDL is only a true threat when it’s oxidized. What oxidizes it? Free radicals. We’re talking trans fats primarily, that beast of an additive found in countless food products (as opposed to foods). What counteracts free radicals (because we all naturally have some in us)? Anti-oxidants: veggies and fruits, of course, as well as nuts, olive oil, etc. Consider also a broad-based multi-antioxidant supplement containing those nutrients shown to decrease oxidation.

Back to the red herring issue. Substantially “elevated” cholesterol, low HDL or high LDL might be reason to give you pause, but not for the reason you might think. The number can tell you that something is amiss, but they’re a symptom of the larger concern rather than the main issue itself. Cholesterol profile can be impacted by other conditions such as hypothyroidism, untreated diabetes or pre-diabetes, pregnancy (surprise!), lactation, stress, liver conditions, heart disease (symptom, not cause of), etc. Talk to your doctor about what your numbers mean in the grand scheme of your health. And see if you can get a read on other markers, like C-reactive protein (an inflammatory indicator) and those small particle LDL numbers.

How to Maintain True Heart Health

Better use two hands...

Now that we’ve conquered the cholesterol frenzy (because the frenzy itself is the real threat), let’s get to the genuine issue of maintaining heart health. Maintaining heart health is about keeping inflammation at bay. As we say here at MDA, that means an anti-inflammatory diet (with exercise), and primal nutrition fits the bill: copious amounts and variety of veggies, fruits, good quality meats, healthy fats and proteins.

Also, plenty of omega-3 fatty acids, particularly fish oil, will thin the blood and help prevent clotting, which along with atherosclerosis (inflammation related), is a serious set up for heart disease and stroke. Fish oil also happens to generally lower triglycerides and increase “good” HDL.

Read up in our MDA archives for additional info on inflammation and healthy living. Thanks for tuning in.

sugar freak, mac vegetarian, Sean Munson, maxgiani, mammabrarian, aussiegall Flickr Photos (CC)

Further Reading:

The Definitive Guide to Insulin, Blood Sugar and Type 2 Diabetes

Vytorin: Big Blow for Big Pharma

PharmaLot: Who Needs Those Cholesterol Pills Anyway?

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  1. Very interesting article, and fun to read.

    As you pointed out heterozygous Familial hypercholesterolemia affects about 0.2% of the US population. For these people it is important to known it is genetic. It will affect treatment and it also means the issue is with you for life (or as long as you have your genome). And then there is sex, if you have FH confirmed by a genetic test then any children you have will have a least a 50% chance of having it. And don’t forget your siblings and parents, same gene pool.


    John O wrote on January 30th, 2008
  2. Pretty comprehensive. It surprised me to find out heart disease has decreased by 50% since the 1950’s.

    McFly wrote on January 30th, 2008
    • I would argue that that statistic is misleading. I’m a fan of MDA and doing Primal myself, but the actual stat was “Death from heart disease, according to the CDC, has declined over 50% since its peak in the 1950s.”

      Part of the reason death from heart disease has dropped is that bypass surgeries and other post-heart-attack procedures have become commonplace. The statistic alone doesn’t tell the whole story (though this also does not negate anything in the article).

      In fact, I would suggest that it’s rather upsetting that we’ve gotten so good at fixing heart disease that CW is blind to its causes in the first place. Grok on!

      Lurker wrote on April 9th, 2012
  3. John O,

    There’s a distinction to be made here: heart disease hasn’t decreased, only deaths from heart disease. We’re getting better at keeping sick people alive through advanced (and extremely expensive) medical technology.

    Sasquatch wrote on January 30th, 2008
  4. Well not only is lowering cholesterol not necessarily going to decrease heart disease, lowering it too much increase vulnerability to colorectal cancer:

    “Surprisingly, a strong association between increased LDL levels and decreased risk of colorectal cancer was identified. The explanation for this finding is unclear.”

    That’s it.

    That’s the total discussion of their most statistically significant finding. Possibly their most biologically significant finding.

    The lowest quartile for men had LDL-C below 100mg/dl, women below 110mg/dl. Those were the ones most likely to get bowel cancer. I think it’s worth pointing out that the average cardiologist would consider an LDL-C of 100mg/dl or above as a peracute statin deficiency. That lowest quartile is where your cardiologist wants you to be.

    Charles wrote on January 30th, 2008
  5. Mark, this is why we all love your blog so much. This was a terrific read that is absolutely correct. Great job.

    Jerry wrote on January 30th, 2008
  6. Excellent post!

    Unfortunately, too heterozygous Familial hypercholesterolemia isn’t the only “hereditary” form of hypercholesterolemia today according to the medical establishment. There are something like 5 types now….if you’re HDL is low it’s one type, if it’s high LDL it’s another…and of course all are treated with statins!!

    There’s been a lot of discussion in the medical world about the “disappointing” results of the recent study indicating lower LDL may not always be good. This is good!!

    Cindy Moore wrote on January 30th, 2008
    • The funny thing about familial hypercholesterolemia is that in a Dutch study, they found that vascular problems were independent of cholesterol. Yet no one would ever publish an article about that little detail. There’s tons of stuff out there against the cholesterol myth, like lower cholesterol is actually more dangerous than high by far, and that low cholesterol can cause serious depression and heighten the risk of hemorrhagic stroke.

      Jay wrote on January 13th, 2011
  7. Funny how cholesterol helps to keep the brain active in older people…and then come statins and lower cholesterol… and then a huge rise in alzheimers…anyone? anyone?

    Mike OD wrote on January 30th, 2008
    • The low-fat craze probably has a lot to blame for that one too…

      mm wrote on July 20th, 2010
      • and we wouldn’t be surprised at all, sadly!

        Patrícia wrote on August 20th, 2012
    • After people ask doctors about why they should stay on statins, they say “oh, they also have anti-inflammatory effets” go figure. All studies done usually use arginine (a friggen amino acid? Sure it creates nitric oxide and all but come on) as a reference point to test statins’ anti-inflammatory process.

      Jay wrote on January 13th, 2011
  8. Wow, very comprehensive you guys! Thank you for parsing all that for me. I feel like I really learned something today. But now my brain hurts and I’m going to bed:)

    charlotte wrote on January 31st, 2008
    • “But now my brain hurts and I’m going to bed”

      Uh-oh, sounds like you need more cholesterol and Omega-3s… 😉

      mm wrote on July 20th, 2010
  9. Nice summary. With high cholesterol and extremely high triglycerides, I’ve been on Lopid for years mainly to protect my pancreas. No health issues other than these symptoms. And then muscle soreness at the gym finally got my GP’s attention that statin side-effects may be something to watch. Finally we get to fish and flax seed oil, reducing carbs, etc. Family history confirms it’s genetic, with lifespans into the 80’s with stroke over heart failure. Dispensing nutrition and exercise prescriptions need at the least same emphasis in western medicine as big pharma.

    Wayne wrote on January 31st, 2008
  10. Hi Wayne,

    Lifespans into the 80s? that’s pretty darn good. In the US average lifespan for a male is a shade over 72 years. Maybe you have Japanes ancestry, Japanese men are the longest lived at 76 and a bit. Why? Probably a combination of many things, public health access, genetics, diet, environment, treatment of elderly, etc. Before I get off topic I will say that family history is one piece of the puzzle and is not necessarily your predetermined destiny.


    John O wrote on January 31st, 2008
  11. Hmm, I have a question. when they talk about inflammation, what are they talking about exactly? So, let’s say I am somewhat active, but keep getting little inflammatory problems (like twisted ankle, sore muscles and joints after working out etc). Will that sort of thing ultimately end up affecting my heart health?

    Raj wrote on February 1st, 2008
  12. Hi Raj,

    That’s an excellent question. Inflammation is often mentioned and not often explained. Getting bruises and twisting your ankle isn’t what he’s talking about here. He’s talking about systemic inflammation.

    My limited understanding is that the word, in this context, refers to the presence of certain harmful biological markers. Things like C-reactive protein and interleukin-18. These are cell stress molecules that are a sign of damage.

    So it’s not inflammation in the sense of “tissue swelling” necessarily; the term has expanded.

    Sasquatch wrote on February 1st, 2008
  13. Very great article – thank you. When I tried to talk with my doctor about statins and asked about the inflamation thing he said “statins reduce inflammation”. I hadn’t heard that – have you a comment about this? thanks!

    saram wrote on February 4th, 2008
  14. Mark, excellent, readable overview on an important topic.

    I’m an MD, and have been concerned about the possibilities you noted: decreasing the serum cholesterol levels impairing the other beneficial cholesterol functions (neural, regenerative, sex hormones, etc). Especially when cholesterols are driven way down, in folks considered at high cardiovascular risk.

    Are you aware of any studies that actually show impairment or negative outcomes, however?

    Peter Beck wrote on March 29th, 2008
  15. Really enjoyed the read! We’re starting to get a better understanding of cholesterol and its role in heart disease. I’ll bookmark your blog and I’ll be back.


    Tim Lazaro wrote on January 16th, 2009
  16. John O.:
    That’s life expectancy at birth. It takes into account people dying very young of accidents and homicides and wars and suicides and goodness knows what else. Your life expectancy as a man at this moment is probably not 72. For example, according to the Centers for Disease Control, in 2005 a 65 year old woman could expect to live another 20 years.

    Karin wrote on April 23rd, 2009
    • The theory is sound and spotprued. The goal was to put out the information in an easy to read and understand way without all the medical and scientific jargon. It has worked for me and others.Thanks for checking it out

      Mari wrote on December 22nd, 2012
  17. Completely agree about the drugs. Our healthcare system is going down the wrong road by encouraging people to treat everything with drugs and by using drugs as the first line of defense rather than as a last resort.

    J. wrote on June 13th, 2009
  18. over 10,000 people a year die from prescribed medications, i was diagnoed high choleterol, have kept it better by exercise and whole grain bread, not much red meat, turkey chicken instead, just had bout with intestinal blockage
    cleared with distilled water, fruits,
    chicken noodle soup. cons also causes high blood pressure. now i am back to 116 over 67 with a 55 heartbeat. i found the article very good thank you. i am going to start a website on natural health, be 70 in five months,
    don’t like that 72 age for death reference lol. i weigh 142 and i am 5ft 10.

    james wrote on July 2nd, 2009
  19. I’m still a little confused.

    as someone who wants to both gain weight and eat low carb, i eat 4 eggs a day.

    is it logical to say that as the liver produces 1400mg of cholesterol, and each egg contains 200mg, that you can safely eat 7 eggs a day?

    In your recent weight gain post you recommend a dozen eggs a day…how come that is safe and healthy?

    Is there a limit to how much dietary cholesteral should be consumed, and is there a direct link between dietary cholesteral and indicators of bad health?

    alex wrote on July 15th, 2009
    • Cholesterol absorption is non-linear at as dietary cholesterol increases. The absorption pathway becomes saturated and a lower relative amount actually gets absorbed as the amount eaten increases. What’s not absorbed passes through in the end (pun intended).

      Ed wrote on November 29th, 2010
    • Low intake of dietary cholesterol causes more cholesterol to be produced.

      High intake of dietary cholesterol causes less cholesterol to be produced.

      (If you want, you can ask Uffe Ravnskov or get his book, it’s truth)

      Jay wrote on January 13th, 2011
  20. Google searches show numerous references that dietary cholesterol increases blood cholesterol, and increased blood cholesterol has been proven to increase the risk of heart disease.

    You seem to be saying (correct me if I’m wrong) that cholesterol is not the cause of heart disease, but inflammation is? Is that to say that there is no limit on cholesterol s long as you keep inflammation at bay?

    very confusing and feels like I am gambling with my health by eating contrary to ‘common knowledge’

    alex wrote on July 15th, 2009
    • I recommend in addition to reason more of Mark’s blog to take a look at “Good Calories, Bad Calories” by Gary Taubes which gives further details as well as an explanation of how the lipid hypothesis became “common knowledge” despite being erroneous.

      Marija wrote on June 3rd, 2011
  21. I echo Alex’s concerns above…

    FDgreen wrote on July 18th, 2009

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