Flipping the Script on High Cholesterol

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🔦 WELLNESS SPOTLIGHT: TO LOWER HIGH CHOLESTEROL…OR NOT?

We've been conditioned to fear high LDL cholesterol, believing it to be the ultimate heart health villain. But what if this narrative is incomplete, even harmful? For many years, the prevailing view has been that high LDL cholesterol is the primary driver of heart disease, strokes, and other cardiovascular disorders. This idea, known as the cholesterol hypothesis, suggests that LDL builds up in artery walls, forming plaques that narrow arteries and lead to heart attacks.

However, emerging research is causing some researchers to propose a more nuanced understanding of how heart disease develops. LDL is increasingly understood as more of an exacerbating factor than the primary initiator of heart disease. Think of it like this: LDL is like putting the wrong fuel in a car with a damaged engine. The wrong fuel makes the problem worse, but it didn't cause the initial engine damage.

Cholesterol: The Basics

• What it is: Cholesterol is a waxy, fat-like substance that's found in all cells of the body. Your body needs cholesterol to make hormones, vitamin D, and substances that help you digest foods.

• Where it comes from: Cholesterol comes from two sources: Your body makes it, and it's also found in animal-derived foods like meat, poultry, and dairy products.

• The Different Types (Lipoproteins): Because cholesterol doesn't dissolve in blood, it must be transported by carriers called lipoproteins. The main ones are:

  • LDL (Low-Density Lipoprotein): Often called "bad" cholesterol. High levels of LDL cholesterol contribute to plaque buildup in arteries.

  • HDL (High-Density Lipoprotein): Often called "good" cholesterol. HDL helps remove cholesterol from the arteries and back to the liver, where it can be eliminated.

  • Triglycerides: These are another type of fat in your blood. High levels of triglycerides, combined with high LDL or low HDL, are linked to an increased risk of heart disease.

Challenging the Traditional View of LDL as the Primary Driver of Heart Disease

In 2016, researcher Vladimir M. Subbotin proposed a hypothesis challenging the conventional understanding of atherosclerosis (a buildup of plaque in the arteries), emphasizing that the disease originates in the vasa vasorum—the small blood vessels that supply the walls of larger arteries—rather than from the accumulation of cholesterol within the arterial lumen.

Key points from Subbotin:

• Blood Supply to Artery Walls: Atherosclerosis may begin from poor blood flow to the artery wall, causing oxygen deprivation and inflammation. Leaky small vessels (vasa vasorum) can deposit cholesterol in the artery wall, with some evidence suggesting cholesterol may enter from outside these vessels.

• Artery Wall Thickening vs. Cholesterol Deposits: Some research suggests the artery's inner lining thickens before cholesterol accumulates, challenging the traditional view that cholesterol deposits are the first step.

• Cholesterol as a Secondary Factor: Cholesterol deposits may not be the primary cause of atherosclerosis but rather a consequence of blood vessel damage and repair mechanisms.

• Active Role of Artery Walls: The inner lining actively controls what substances enter the artery wall, suggesting cholesterol may not directly enter from the bloodstream as previously thought.

• Importance of Artery Wall Injury: Research indicates that damage to the inner lining (intima) is a critical first step in developing atherosclerosis, rather than cholesterol simply entering healthy artery walls.

Ivor Cummins, a chemical engineer, has reshaped the discussions around the important risk factors that result in coronary artery disease. In this insightful video, he discusses the contemporary debate around this heated topic:

Focus on the Root Causes of Artery Damage

If damage to the intima is the trigger, what causes this damage? Here's where the focus shifts from solely blaming LDL to identifying the root causes of artery injury:

• High Blood Sugar: Elevated and fluctuating blood sugar levels can damage the delicate cells lining the arteries.

• Inflammation: Chronic inflammation, driven by factors like diet, stress, and infections, can weaken the arteries.

• Oxidative Stress: An imbalance between free radicals and antioxidants can damage artery walls.

• High Blood Pressure: Excessive pressure can injure the intima.

• Nutrient Deficiencies: Adequate vitamins and minerals are essential for maintaining healthy artery walls.

• Infections and Smoking: These are known to promote inflammation and artery damage.

Rethinking the "Bad" in LDL Cholesterol: Is It the Whole Story?

For decades, the cholesterol hypothesis has driven our understanding of heart disease. However, some researchers are now questioning whether high LDL cholesterol is a reliable predictor of cardiovascular risk, suggesting that the relationship may not be as linear as once believed.

• LDL Levels and Heart Attacks: A study by the American Heart Association found that out of 136,905 patients between 2000 and 2006, nearly 75% of individuals hospitalized for heart attacks have LDL levels that would not classify them as high risk according to current guidelines. In fact, LDL-C levels in patients experiencing acute myocardial infarction are often lower than normal (Ravnskov et al., 2018).

• Beyond Cholesterol: A 2009 Cleveland HeartLab study showed that about half of the people hospitalized with coronary heart disease had 'normal' LDL levels (under 130mg/dl) but high levels of inflammation.

• Saturated Fat Doubts: A 2010 meta-analysis found no association between saturated fat intake and heart disease (Siri-Tarino et al., 2010).

• Lower Isn’t Always Better: A 2010 Japanese study challenged the assumption that lower cholesterol is always better, especially regarding longevity (Okuyama, 2010).

• Key Findings from Japan: Men with LDL cholesterol levels between 100 mg/dL and 160 mg/dL had lower death rates compared to those with lower LDL. Even stroke patients with high lipid levels experienced lower death rates and milder symptoms. These findings suggest cholesterol may be vital for cell membrane integrity and hormone production, challenging the "lower is always better" idea.

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A Historical Perspective: The Beginning of ‘Bad’ Cholesterol

•  Seven Countries Study Critique: Ancel Keys' Seven Countries Study, a cornerstone of the cholesterol theory, has been criticized for selectively using data from only 7 out of 22 countries to link saturated fat, cholesterol, and heart disease (Rosch, 2008).

• Framingham Heart Study Findings: The 1972 Framingham Heart Study revealed that half of heart attacks occurred in individuals with normal or low cholesterol levels. Surprisingly, higher saturated fat and cholesterol intake were associated with lower serum cholesterol (Castelli, 1987).

• MRFIT Trial Results: The Multiple Risk Factor Intervention Trial (MRFIT) aimed to reduce coronary heart disease mortality by lowering cholesterol and other risk factors. While the intervention group had slightly fewer heart disease deaths, their overall mortality increased due to other factors.

The discussion surrounding heart disease is complex, filled with conflicting information. The controversial documentary "The Heart of the Matter" challenges many of these a dogmatic assumptions, urging viewers to reconsider what they know about cholesterol and heart disease.

This isn't to say that high LDL cholesterol is irrelevant and should be ignored—far from it. By understanding the complexities and controversies surrounding the cholesterol hypothesis, we can have more informed conversations with our healthcare providers and make decisions that are truly best for our individual health.

Here's a look at some promising research for managing cholesterol naturally:

1. The "Dietary Portfolio": Your All-Star Cholesterol-Busting Team!

Research shows that a strategic combination of cholesterol-lowering foods, known as a "dietary portfolio," can be remarkably effective—comparable to a low dose of a first-generation statin.

The Portfolio Power Players (Jenkins et al., 2003):

• Plant Sterols (1.0 g/1000 kcal): These compounds block your body from absorbing cholesterol. Find them in enriched foods and supplements.

• Soy Protein (21.4 g/1000 kcal): Swap out some animal protein for soy! Think tofu, tempeh, edamame, soy milk, and more.

• Viscous Fibers (9.8-10 g/1000 kcal): This is where oatmeal, barley, psyllium, okra, and eggplant shine.

• Almonds (14 g/1000 kcal): A delicious and heart-healthy snack!

The Results?

• This dietary portfolio achieved an impressive average LDL cholesterol reduction of about 13.9% to 29%.

• For comparison, Lovastatin (20 mg daily) lowered LDL cholesterol by about 21.0% to 33%.

• A surprising 26% of participants achieved their lowest LDL cholesterol levels using the dietary portfolio alone.

2. Oat Beta-Glucan: A Fiber Powerhouse

Oat beta-glucan (OBG), a soluble fiber found in oats, is well-known for its cholesterol-lowering benefits. A recent study found that drinking a beverage with 3 grams of OBG daily for 4 weeks significantly lowered LDL cholesterol (Othman et al., 2022).

Actionable Steps:

• Increase OBG Intake:  One and a half cups of cooked oatmeal or three packets of instant oatmeal contain approximately 3 grams of OBG.

• Consider a Beverage Form: Add oats to your morning smoothie for convenience.

• Check Labels:  Some specialized barley lines, such as BARLEYmax®, contain higher levels of beta-glucan.

3. Green Tea EGCG: A Sip Towards Lower LDL

A systematic review of 17 studies found that consuming 07-856 mg of Epigallocatechin gallate (EGCG), a powerful antioxidant in green tea, resulted in a reduction of LDL cholesterol over 4-14 weeks (Momose et al., 2016):

How to Incorporate EGCG:

• Drink Green Tea: Aim for 2-3 cups of green tea daily. Note that the EGCG content in green tea can vary depending on the type of tea and brewing method.

• Consider Extracts: Consider green tea extract supplements if you don't like green tea or can't drink enough.

4. Water-Soluble Dietary Fiber Mixtures: The Power of Psyllium, Pectin, Guar, and Locust Bean Gum

A study showed that a water-soluble dietary fiber (WSDF) mixture can be beneficial, lowering LDL cholesterol by binding bile salts and reducing blood glucose levels. In the study, taking a specific fiber mixture three times daily lowered plasma total cholesterol by 10% and LDL cholesterol by 14% (Jensen et al., 1993). 

Each 5-gram serving contained:

• Psyllium (2.1g)

• Pectin (1.3g)

• Guar gum (1.1g)

• Locust bean gum (0.5g)

5. Red Yeast Rice: Nature’s Statin

RYR is produced by fermenting rice with the mold Monascus purpureus, which gives it a reddish-purple hue. This fermentation process generates compounds called monacolins, with monacolin K being the most notable, as it is chemically identical to the statin drug lovastatin (Healthline, 2023; Medical News Today, 2023).

• One study showed a 16% reduction in total cholesterol, a 21% reduction in LDL, and a 24% decrease in triglycerides over 12 weeks (American Heart Association, 1999).

• Another study reported a 22.7% decrease in total cholesterol and a 31% decrease in LDL (European Journal of Cardiovascular Prevention and Rehabilitation, 2005).

• It’s worth mentioning that a significant percentage of red yeast rice products can be contaminated with citrinin, a mycotoxin of concern that can cause kidney and liver damage. An ongoing investigation in Japan is probing whether RYR supplements are the cause of several dozen deaths.

• The lack of regulation over RYR supplements means that consumers should be especially vigilant about the monocolin-content, which often isn’t specified on labels.

A Balanced Approach to Heart Health

The conversation around cholesterol and heart disease is evolving and we should approach the emerging evidence with an open mind. While traditional views have emphasized LDL cholesterol as the primary villain, some researchers suggest a more complex picture where arterial damage may precede cholesterol accumulation. This doesn't mean we should ignore cholesterol levels, but rather place them in a broader context of cardiovascular health.

A holistic approach to heart health might include:

• Addressing potential root causes of arterial damage, such as inflammation, high blood sugar, insulin resistance, and oxidative stress.

• Implementing evidence-based natural interventions like the "dietary portfolio," oat beta-glucan, green tea, and high fiber diets alongside a pharmaceutical approach.

• Recognizing that very low cholesterol isn't necessarily better for overall health and longevity.

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