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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.

Preposterous.

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?

(10R,13R)-10,13-dimethyl-17-(6-methylheptan-2-yl)-2,3,4,7,8,9,11,12,14,15,16,17-dodecahydro-1H-cyclopenta[a]phenanthren-3-ol

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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You want comments? We got comments:

Imagine you’re George Clooney. Take a moment to admire your grooming and wit. Okay, now imagine someone walks up to you and asks, “What’s your name?” You say, “I’m George Clooney.” Or maybe you say, “I’m the Clooninator!” You don’t say “I’m George of George Clooney Sells Movies Blog” and you certainly don’t say, “I’m Clooney Weight Loss Plan”. So while spam is technically meat, it ain’t anywhere near Primal. Please nickname yourself something your friends would call you.

  1. Thanks Mary. What’s worrying me is I’m trying to put on a little weight, but how can I do it without worsening my cholesterol. E.g. the 12 eggs on the other post. My cholesterol’s borderline high already, but wouldn’t eating all those eggs make it even worse? I read through this page and the posts, and it’s the posts where people’s bad levels of cholesterol went Up that worry me, because how would you ignore That? I know cholesterol is beneficial for different things, but too much of anything, esp HDL isn’t good!

    B.B wrote on November 30th, 2010
    • Every day for breakfast I have a four-egg omelet that has coconut oil, bacon, cheese, and sun-dried tomatoes (& occasionally freezer-dried blueberries- don’t laugh until you’ve tried it.)

      My total cholesterol is under 160. I’m trying to increase mine to 180.

      Ed wrote on November 30th, 2010
  2. Thanks Ed. What’s your cholesterol like? I’d still love to gain muscle /weight without going too far in the wrong direction. Should I just go crazy on the fats? Does anyone have meal ideas for a healthy weight gain? I’m 128 lbs (female), trying to gain a little weight

    B.B wrote on December 13th, 2010
    • I’m a bit of a geek, so I already had a spreadsheet with food values from the USDA National Nutrient Database. With that spreadsheet and a set of scales, I was able to determine how much fat (& which types), protein and carbohydrates I ate.

      I pretty much eat the same breakfast, lunch and snacks everyday, so I decided to change my diet slowly. This was important for me because adding fat to my diet allowed my body to handle the additional load intestinally.

      Gaining weight has never been my goal (just the opposite). I can provide advice on unhealthy ways to gain weight, so I can’t help you there.

      Ed Terry wrote on December 13th, 2010
  3. Have you read Anthony Colpo’s “The Great Cholesterol Con?”

    Not to mention the simple fact that 75% of people who have heart attacks have normal cholesterol. The lipoid hypothesis used 7 countries when there were 22 countries with data available. Also, if you look at MONICA, the fact you can keep the cholesterol myth alive is just astonishing, as there is little-to-no correlation between deaths and cholesterol.

    Other good reads were Dwight Lundell’s “The Great Cholesterol Lie” and Uffe Ravnskov’s “Fat and Cholesterol are good for you.”

    I haven’t believed the cholesterol myth for quite some time, nor the “Metabolic Syndrome” or “Syndrome X.” There was also a post in the Colombo Herald where I read they were going to put statins in our fast food! What in the world? And also they recommended kids as young as 6 have statins, sure, money is definitely not a factor.

    Jay wrote on January 13th, 2011
  4. I’m not buying the whole ‘anti-oxidant’
    hype. The ant-oxidants found in plants are FOR THE PLANTS! Cancer, tumors, bacteria,fungals, and whatever other bad guys are anaerobic by nature, not aerobic. Anaerobic=no oxygen, aerobic=oxygen. So why would you take
    “anti” oxidants?

    keithallenlaw wrote on February 15th, 2011
  5. Instead of “aligned” I think you mean “maligned”.

    Bopis wrote on August 6th, 2011
  6. Well, looks like I’m not alone in this. :)
    After about 2 months in a non-radical Primal lifestyle:
    # Fasting Glucose = 86 [mg/dL]
    # Blood Pressure: 90 / 50 [mmHg]
    # Total Cholesterol = 275 [mg/dL]
    # HDL = 56 [mg/dL]
    # LDL = 210 [mg/dL]
    # Triglycerides = below 90 [mg/dL] (too low for the chemist’s machine to get right)

    Now, I’ve stumbled upon a very interesting article that clarifies that the most telling indicator of CVD risk is actually TG/HDL. If you’re below 2.0, you’re ok.
    http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2664115/

    Assuming a TG count anywhere between 70 and 90, this yields for me:
    # Trigl./HDL = 1.25 ~ 1.60

    So, although the doctors in my family are scared about my LDL=210, I’m ok with it because I know that I have a pretty low Trigliceride level and a relatively good HDL. Plus, the blood pressure is pretty low. And, of course, I’ve become pretty leaner and stronger too.

    The reason I speculate a 70 < TG < 90 is because I had TG=73 a couple of years ago when doing Paleo (without sat fat). And now that I'm doing Primal with lots of sat fat and very little carbs, I expect to see the TG drop even lower.

    So, Mark and all the guys and gals here, what do you have to comment on this study I linked up?

    Vasco Nevoa wrote on August 30th, 2011
  7. Mark, There has been substantial evidence that saturated anima fat promotes arterial disease. Even so-called grass fed beef. There was a man who was on the Atkins diet who sued Dr. Atkins when he developed heart disease after 1 year on his high fat animal diet. For that reason I do not eat red meat, instead I eat lean turkey breast which I boil in hot water to reduce the fat even more. I do think your understanding of the correct diet for the human specie is right on the money.. However, too many carbs can easily sabotage this diet. Grok was, after all ,on a very low carb diet with only seasonal fruit as his main carb. Please respond, thank you

    charles monmiller wrote on November 3rd, 2011
    • I just ate a big steak, a bunch of kale wilted in cocunut oil with some whole cream dripped over it.

      Everyone (mostly coworkers)comments on my physical improvement as I am obviously leaner, more muscular and strongerthan severalmonths ago. Then they don’t believe me despite my improved lipidprofile over last year before transitioning to primal.

      Then they gawk when we go out to eat and I get a 16 ounce pork chop T bone and put butter on top! .

      Thanks Mark for helping shatter a myth.

      Bryanccfhsr wrote on November 3rd, 2011
    • Charles, please don’t come in here and rant about “substantial evidence” that you don’t bother to provide links for. It’s rude.
      Also, I hope you enjoy that boiled turkey breast. Yes, indeed, that just sounds yummy! You know, even if Mark and the hundreds of thousands of paleo/primal eaters in the world, not to mention the millions of ancestors throughout history turned, out to be wrong, I’m OK with it. I’d rather die young, happy, and well fed than live to be a 100 eating the disgusting crap you just described.

      Deanna wrote on March 23rd, 2012

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