Medicine is a strange beast. The process of how medical hypotheses become established fact has to do with our historical approach to scientific inquiry. The great part about science is that it is very good at admitting when it has made a mistake.

It seems much of what we have been taught about cholesterol may be wrong. Why? Because science is now proving this.

Our livers produce between 70-90 percent of our body's cholesterol. So even if we didn’t eat any cholesterol, we would still have cholesterol in our body, which is important especially when considering that it’s an essential requirement for neurogenesis (formation of new brain cells) and is utilised by all  cells to produce cell membranes.

Induction vs Deduction in the Scientific Method

You may have heard the expression “Medicine isn’t an exact science” before. What this means is that every major medical theory starts out as an idea in an individual researcher’s head (or sometimes more than one). Up until the middle of the 19th century all medical knowledge was based on the deductive method – nature and diseases were observed and then a hypothesis was deduced. In the 20th century our knowledge base grew so much, that researchers started ‘inducing’ observations based on previous ideas. This had significant effects on the way we formulated theories. The 20th century also saw the birth of modern genetics and large-scale sharing of research across continents – influencing and promoting the inductive method of thought.

As for the idea that cholesterol was bad for cardiovascular health, we have to go back to over 100 years ago, to see how this hypothesis was birthed. The first tentative suggestion that high cholesterol caused atherosclerosis (when the artery walls become thicker as a result of fatty substances and calcium accumulating) in humans occurred in 1889. Back then Rudolf Virchow, a German pathologist, reported on an autopsy he performed on a young boy who had had genetic disorder that resulted in massive overproduction of cholesterol. This boy had died at age 11, with large ‘atherosclerotic-like’ lesions (plaques) in his arteries.

Then in 1913 a Russian study, conducted in rabbits, showed that when these rabbits were fed a high cholesterol diet, an increase in these lesions was observed. However, the results could not be replicated in rats and dogs, so the findings were largely inconclusive. One argument put forward against this, was that rabbits exclusively feed on plant-based substances and that a high cholesterol diet was unnatural for them.

On top of this rats and dogs are efficient at converting cholesterol to bile acid which gets excreted. So that study was largely discredited.

The Light Bulb Goes On

Heart attacks have claimed the lives of millions in the Western world over the last century.

Why is this?

During the early 1950s, the beneficial properties of omega-3 fats (fish, flaxseed, krill) and mono-unsaturated fats (olive oil) in aiding cardiovascular health were not known to the medical community.  People largely didn’t pay attention to what they were eating and smoking was de rigeur (even in doctor’s offices,) in those days.

Then in 1955, a large-scale, multinational study investigated the dietary habits of several nations in relation to relative cardiovascular risk. The study found that heart attack numbers were exceptionally high in Finland, but very low in Japan. Interestingly the Finnish ate the highest amount of saturated fats in the study and the Japanese the lowest. The Finnish also boasted the highest cholesterol levels (and again, the Japanese the lowest.) So the first tentative conclusions were drawn.

It still took most government health authorities nearly 30 years to catch on to these discoveries and implement health guidelines for physicians to follow.

Cholesterol is Important

Cholesterol is a fat (lipid) that has significant functions in the body (like organising and maintaining cell membranes, being the building block of some lipid-soluble vitamins and hormones like testosterone.) It resembles a wax-like substance, a bit like the wax flakes that come off of a yellowish candle. It moves throughout the body via the bloodstreams. Yet blood is water based whereas fats are oil-based, so the two don’t really mix well. To prevent cholesterol from congealing, our body packs it into substances called lipoproteins.

In order for us to function at our best, our body makes around 1 gram of cholesterol every day – elegantly making up for “lost” cholesterol that we are not getting from our diet.

Dietary Fats: Not all the Same Fat

All fats are comprised of a chain of carbon atoms that are bonded to hydrogen atoms. Our bodies react differently to different fats. The difference between fats is the number of hydrogen atoms and the shape the carbon atoms manifest themselves in, due to the number of hydrogens bound – this determines the shape and length of the fat.

Saturated fats have a higher number of hydrogen atoms than unsaturated fats (hence they are called ‘saturated’, referring to the fact that the carbon chains are saturated with hydrogen atoms (i.e. cannot bind to any more hydrogens).

On the flip-side, unsaturated fats have less hydrogen atoms. There are two different kinds of unsaturated fats: polyunsaturated and monounsaturated. Polyunsaturated fats, like omega-3 fats and omega-6 fats, have four or more carbons that are not saturated with hydrogen. Monounsaturated fats have just one pair of carbon molecules that are not saturated with hydrogen. Having space in the carbon chain for more hydrogens, means that unsaturated fats serve a purpose by binding to other ‘loose’ hydrogens in the body that may have been released due to oxidation reactions occuring with other molecules.

There has been some debate in the international medical community as of late regarding the consumption of saturated fats versus unsaturated fats when it comes to obesity, cardiovascular health and cholesterol. The consensus used to be that all saturated fats were “bad” for health, increasing cardiovascular events and promoting diabetes. However, recent clinical trials have suggested that saturated fats may not be that bad after all. Furthermore, a recent study on heart attacks indicated that nearly 75% of all heart attack sufferers had normal cholesterol levels.

So it seems that 40 years of medical “fact” interpretation is being turned on its head. There are two main types of cholesterol ‘packages’ – low density and high density:

Low-Density Lipoproteins (LDL)

LDL’s main role is to take cholesterol to those parts of the body that need it. Common medical consensus is that if there is too much LDL in the bloodstream, parts of the cholesterol ‘package’ (the triglyceride component) gets deposited in the arteries, which in turn form plaques that can cause blockages and lead to heart attacks. This is why LDL is often referred to as the “bad” (or even “ugly”) cholesterol. But it still serves a very important function. However, too much of it can lead to complications. The amount of LDL circulating in the blood is believed to be related to the amount of saturated fat we eat.

In 1979, researchers began making discoveries indicating that it is the oxidation of LDL that results in the most arterial damage. Oxidation of LDL results in endothelial cells lining the blood getting injured and in turn causing inflammation. Yet it was not until 1984 when the medical establishment ‘officially’ recognized the relationship between high cholesterol and heart attack incidence.

What’s the deal with Statins?

In 2004 the US National Institute of Health (NIH) lowered the recommended ‘healthy’ baseline LDL levels from just under 100 (mg per decilitre) to just below 70 (set in 2002). As most of the western world follows the advice given by the NIH, this resulted in a massive increase in the number of people diagnosed with high cholesterol. As a result of this pharmaceutical companies posted profits in the 10s of billions of dollars from increased sales of cholesterol-lowering drugs. One drug in particular (in fact the most successful drug of all time) Lipitor (a statin drug) was over-prescribed to such an extent that otherwise healthy people were reporting severe side effects – one of the most damaging effects of statins is that they cause muscles to degenerate (as well as the heart, which is a muscle).

Two days ago, on Tuesday the 12th November 2013, the American College of Cardiology and American Heart Association issued new guidelines around statin prescriptions – stating that some 70 million Americans should be discussing statin therapy with their physicians. They have even created an online calculator that assesses relative risk (using varying factors such as age, weight, BMI, ethnicity to gauge the risk of a cardiovascular event.) This in light of the fact that statin drugs have been implicated with a 71% increased risk of developing diabetes in women – as well as the damage they do to the actual heart muscle itself.

Perhaps counter-intuitively, 8 months prior to this, in February 2013, the scientific journal Nature reported that the NIH would be reviewing its baseline LDL recommendations again, presumably increasing the number from 70 back to just above a hundred (where it was in 2002).

Some physicians have argued that atherosclerosis and coronary artery disease is all about inflammation and response to physical injury to the wall lining the artery (endothelium) and has nothing to do with LDL cholesterol. What these doctors overlook is the fact that oxidised LDL injures endothelial cells and in turn causes inflammation. This inflammation is what causes the artery walls to narrow and make them more susceptible to plaque formation and subsequent damage promoting the risk of a cardiovascular event.

High-Density Lipoproteins (HDL)

HDL is the opposite of LDL. HDL is made up of mostly protein (high density particle) and low fat. HDL acts like a hoover that removes excess cholesterol from the peripheral cells and tissues and brings it back to the liver for recycling (or to make bile). Due to this cleaning role, higher levels of HDL have been tentatively linked to a decreased cardiovascular risk and heart disease. High-fat diets that have been implicated in raising LDL levels also appear to  raise HDL.

Low -fat diets decrease both types. This presents us with a double-edged sword.

Hence the recent proclamations by Harvard University and the Swedish health authorities that diet high in fat can actually be beneficial for heart health and overall well-being, as well as lowering obesity rates. The really “bad” fats are trans-fats (as found in margarine and other butter substitutes). In fact the research pointing this out is so vast that this week, the Federal Drug Authority (FDA) in the US decided to put an all-out ban on their production in America!

The Optimal Cholesterol Diet/Lifestyle

I know a lot of this information seems confusing, but that’s because it is! There is no common consensus among physicians and researchers regarding optimum cholesterol levels and as such it can be daunting as to what to do or who to trust.

But one thing is for certain, what we put into our body is very important.

Bottom line: Eat leafy green vegetables. That means load up on spinach, silver beet and lettuce. Also, aubergine, goats cheese, kale, nuts, broccoli and garlic are great ‘heart’ foods!

Try to avoid gluten and sugar where possible. As both gluten and sugar affect insulin and maintaining a diet that looks out for insulin levels may help maintain stable cholesterol levels, as cholesterol is made in the liver (which in turn is affected by insulin levels).

Fermented foods are good – as these increase the presence of beneficial bacteria in our gut, a decrease in these bacteria in the gut has been linked to a decrease in heart health. A healthy way to get these friendly bacteria into your system is to brew komboucha tea – which contains symbiotic colonies of bacteria and yeast. There are some great recipes online.

Also, there has been some debate about eggs and their impact on cholesterol. Although eggs do contain higher amounts of cholesterol, they also contain high levels of lecithin (a fat molecule that contains important nutrients, such as choline, phosphate and fatty acids). The choline part of lecithin counteracts the cholesterol consumed in the egg. Without adequate amounts of lecithin, the levels of cholesterol and fat can build up within the liver. This cholesterol/lecithin balance within eggs only applies when they’re from organic free range chickens.  Studies show battery-produced eggs contain twice the normal cholesterol and no lecithin.

Another really good reason to only eat organic produce!

See if you can eat half of your food raw – this way you will increase the amount (yield) of nutrients your body assimilates directly from the food you ingest.

Recent clinical studies have suggested that pomegranate may confer benefits in preventing the oxidation of LDL cholesterol. So if possible, try to find a good source for pomegranate (or its extract).

Fruit smoothies in the morning are excellent – try adding kale, silver beet or parsley to your smoothie (won’t affect taste and then your fruit smoothie becomes a fruit and veg combo smoothie- yum!).

Another great lifestyle adjustment is to get a lot of sleep  – as recent research is showing that our brains regenerate when we sleep! So get plenty of it (and do naps during the day)! Of course exercise is good (at least 20 minutes every day) and of course reducing alcohol intake and stopping smoking, will help your heart and cardiovascular system. Get out in the sun to source your Vitamin D – also the sun is related to happiness and we all know being happy makes us healthy.

But you know most of this already.

Supplements that lower LDL levels

Red Yeast Rice has been linked to maintaining optimal cholesterol levels by providing nutritional elements for our circulatory system. Red yeast rice lowers optimal co-enzyme Q10 levels, so supplementing with this to make up for lower levels, is important.

Ubiquinol and co-enzyme Q10 protect against the damaging inflammation as a result of LDL oxidation described above. Those people taking statin medication, should be aware of the fact that statins reduce the presence of co-enzyme Q10 in the body, so supplementing with this may help as well. Even if you are not on statins, co-enzyme Q10 is a great supplement to take for heart health in general (as our bodies slow down production of this critical enzyme from about age 40). Co-enzyme Q10 is broken down and stored in the body as ubiquinol – which is another supplement to be aware of (ubiquinol is absorbed more rapidly by the body – so makes sense for people over the age of 50).

Vitamin E is a lipid soluble antioxidant which may confer health benefits in people with cardiovascular complications. Vitamin D is instrumental in conferring the structural integrity of the arteries and veins and may prevent the plaque build-up of triglycerides from LDL-dumping.

Clinical trials have suggested a health benefit in supplementing with krill oil and fish oil. A decrease in total cholesterol has been noted with krill oil, to a fairly normal degree in clinical studies. Fish and krill oil contain the two fatty acids: eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA) that confer the health benefits. They may reduce the cardio-metabolic risk by lowering the number of other lipids circulating, and help maintain blood vessels with less risk for plaque build-up. Some studies have suggested that even as little as 500mg of krill oil may help maintain healthy levels of cholesterol (by reducing the triglyceride ‘dumping’ by LDL).

Probiotics promote heart health as well as boosting immunity by providing a stable population of beneficial bacteria in the gut – so supplementing with them is a sensible idea.

In summary, to lower LDL levels and prevent LDL oxidation is not easy but it is possible.

Hopefully this article has motivated you to start thinking about your heart health and that it has also given you a bit of insight into cholesterol, its history, and its dual role in our bodies – more research is needed as the sea of information out there is hazy at best, but it’s safe to say that when it comes to our knowledge and understanding of cholesterol the news is good, bad and a certainly a little bit ugly.

by Christopher von Roy BSc, MSc, DCP Immunology



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