Cholesterol

Introduction

Most of us would have heard about cholesterol. For many, it’s hardly the kind of thing you would talk about at a nightclub or your next healing session in Bali; but once you reach that special part of life called middle age, you’re bound to feel the need to bring it up at dinner events as if people care. Sadly, cholesterol is a part of life for all of us and we need to know something about it.

Cholesterol is a well known risk factor for heart disease. Cholesterol describes a range of fats and molecules carrying fats in the body. Whilst it is true that higher levels of cholesterol are associated with higher rates of heart attacks and stroke, the nature of the cholesterol also matters.

Much of the time, cholesterol is just cholesterol; normal fat molecules are meant to be in the blood system from time to time. However, there are forms of cholesterol that are associated with disease. These are the smaller cholesterol and the ones that are ‘dirty’; modified by inflammation in the body to be more reactive when they interact with arteries and the heart.

If cholesterol is ‘oxidised’, that is that inflammatory free radicals have altered the molecule, it is more likely to stick to the inside of an artery wall and thus, over time, block the artery leading to downstream heart attack or stroke etc.

Smoking, alcohol, junk food etc. are all risk factors for this. This article will walk you through the common forms of cholesterol.

What forms of cholesterol are there?

LDL: Low Density Lipoprotein

LDL is a smaller sized particle of cholesterol. It is commonly known as the ‘bad’ cholesterol. This kind of cholesterol is known to stick to the inside of arteries and clog up blood vessels. LDL, especially when oxidised, is well known to cause heart disease. Ideal is 1.8-2.4 mmol/L.

LDL a bit higher than 2.4 mmol/L is very common. This is not known to be a risk factor per se unless there is a reason for the LDL to be ‘oxidised’. Think about the unhealthy smoker who drinks a pint of wine a day; he may have an LDL 2.5 mmol/L but it is far more likely that this is oxidised compared with the fit, active, vegetarian who happens to have LDL of 3.4 mmol/L.

Rule of thumb; It’s not just the LDL level that matters but the other risk factors put together!

VLDL: Very Low Density Lipoprotein

This cholesterol transports useful fats to the cell membranes

HDL: This cholesterol is also the return molecule for fat transport; that is, it brings cholesterol out of the artery too; it is the ‘good cholesterol’. Ideal is >1.5 mmol/L

TAG: Triacylglycerides are the main form of fats released into the blood after we eat a fatty meal. If they are raised throughout the day, they also deposit in blood vessels. Ideal is <1.3 mmol/L

What is atherosclerosis?

High cholesterol, and associated oxidative damage, hits the artery well and causes that cell to make plaques. This is a fatty deposit full of platelets, cell debris, immune cells that occupies space and eventually blocks an artery.

What is important to remember is that this process is goign on all the time. Autopsies on car accident victims even in their 20s will show some plaque formation; called atherosclerosis.

In the early stages, this is ‘soft plaque’. This kind of plaque has not attracted calcium deposits and so appears soft on CT imaging (a kind of 3D Xray). It is generally accepted that whilst plaque is in the ‘soft’ stage, the process can be reversed with treatment (whether lifestyle, supplements or medications or all three).

This is important, because this is the phase of the atherosclerosis we want to treat. This is why we check young healthy people for high cholesterol and pay attention to people with risk factors for high cholesterol; such as smoking, obesity or a family history of cardiovascular disease.

Once the plaque in an artery stays around long enough, it will attract calcium and form almost like a hard bone. This is hard plaque and is much harder to reverse.

How does plaque cause disease?

In small blood vessels, the endothelial dysfunction and the associated plaque can cause microvascular disease. Blockage of small blood vessels such as capillaries can lead to a higher chance of problems like erectile dysfunction, memory loss, and cognitive decline.

It can even impact the eye and lead to vision loss.

Once a big artery is affected, the blood flow will be blocked and the cells, organs and tissues that needed that blood will die. In the brain, this is a stroke. In the heart, this is a heart attack. This can be a devastating process; once those cells are dead they are permanently lost and the result is permanent for the patient.

The whole point of knowing about cholesterol is to avoid getting to this stage.

What are the risk factors for high cholesterol and cardiovascular disease?

There are many factors which act to raise cholesterol.

For a bit of background, read the article on insulin resistance. This article describes how the body has a set of ‘distress’ reflexes when it runs out of vitamins, cannot clear toxins, encounters too many toxins etc. that push it to raise sugar, raise insulin and also raise cholesterol.

In a nutshell, when the body is unhappy in a chemical way, it will panic and start to conserve calories and lower hormones. This is the metabolic syndrome we talk about in diabetes.

As a part of this active, ongoing fight, more LDL will be released. In the same setting, the body is running out of vitamins to fight oxidative damage and so more of the cholesterol will be oxidised and harmful to arteries.

Some of the risk factors that feed into this pathway include

• Smoking
• Drug use
• Alcohol
• High junk food consumption
• Poor diet (lack of vitamins and fibers that the body needs to fight toxins and run its cells)
• Family history
• Genetics
• Certain medications (E.g. roaccutane for acne)
• Liver disease (prevents the liver getting rid of toxins)
• Environmental pollution
• Heavy metals

The easiest way to think about it is to think about the body not being in a perfect environment. If the food and vitamins required are not enough or the toxicity is too much or not getting cleared; the body will be unhappy and this will result in dirty cholesterol hitting the artery wall.

Is there a genetic component to high cholesterol?

Family history is important in cholesterol and cardiovascular disease in general.

If there is a family history  of high cholesterol, a person should check their cholesterol and actively manage a high cholesterol. This might not mean we must use medications per se, but lifestyle and supplements might be a starting position.

Some families will have specific genes which give a higher chance of high cholesterol and heart disease. One example is the ApoE genes. There are many others that can be tested for. If you have unexpected and high cholesterol (especially when young) it is recommended to have genetic testing to see if you have a risk factor for high cholesterol. If you have this gene, your doctor might recommend early lifelong treatment with a cholesterol lowering medication to reduce your future risk of cardiovascular disease.

So what kinds of cholesterol should I be worried about?

As stated before, it is normal to have some cholesterol. Whilst a higher LDL is associated with heart disease, a total assessment of all of the risks of somebody having a heart attack is more important than any one high cholesterol reading on a blood test. This includes taking into consideration family history, diabetes, blood pressure, smoking etc. There are calculators online that are commonly used for this purpose by doctors.

Cholesterol is ultimately only one of the risks for a heart attack. Multiple things can contribute to arterial disease leading to plaque.

For example, 72% of heart attack victims have normal cholesterol and 13% have no risk factors.

In addition to the amount of the cholesterol, the nature of the cholesterol matters too.

LDL can be oxidised or not oxidised. Oxidised describes damage from the transfer of electrons; this is part of cellular processes. If somebody exercises, has a healthy diet and does not smoke, they will have less ‘oxidative damage’ in their body. (Further reading, oxidative damage article)

If LDL is oxidised, it is more likely to attach to the inside wall of a blood vessel and lead to atherosclerotic heart disease; this means plaques that form inside the artery wall and can clog up blood flow to the brain and heart (leading to stroke and heart attack).

It is not just plaque formation that gives us a heart attack or stroke. Dirty or oxidised LDL or TAG hitting an artery wall also upsets the cells in the artery wall. This process involves dysfunction of the cells of a blood vessel wall which promote inflammation and the buildup of dangerous plaque.

Collectively, this is called ‘Endothelial Dysfunction’; and may account for why some people with low LDL suffer heart disease and blood vessel dysfunction when they have other risk factors like smoking.

As such, when testing cholesterol, it is best to consider testing for oxidised LDL as well if risk factors are present. Sometimes doctors will test for high sensitivity CRP to get an idea of this chance of oxidation.

How can I treat high cholesterol and reduce the chance of endothelial dysfunction?

We mentioned before that high, and oxidised, cholesterol is associated with inflammatory lifestyle conditions. An unhappy body with lower vitamins, more toxins and poor diet will probably have more cholesterol and more oxidised cholesterol.

Treating overall health is thus essential to lowering cholesterol in the first place.

Treating high cholesterol starts with lifestyle measures;

• Reduce toxicity; air filters, water filters
• Clean eating: high fiber, vegetables, good vitamins
• Replace deficient vitamins: such as B vitamins
• Support the body to reduce inflammation; coenzyme Q10, regular fasting, regular exercise help the body manage inflammation
• Avoid smoking
• Avoid saturated fats such as junk food

Often, lifestyle measures are enough to help lower the cholesterol and more importantly, lower the amount of oxidised cholesterol.

We also have to think about endothelial dysfunction; the activation of blood vessel cells when hit by bad cholesterol which leads to plaque.

Fighting endothelial dysfunction involves the above measures with an emphasis on:

Adequate nutrition including Zinc, B vitamins and vegetables Coenzyme Q 10

Regular exercise

Regular fasting

Avoiding stress to the body such as alcohol, smoking, or industrial pollution

Resveratrol

Fish Oil helps boost HDL to protect the arteries; as does omega 3 derivatives

If these measures alone do not work and the LDL remains high, there are a number of supplements which can be used to lower cholesterol. Often they aim to reduce the inflammation in the body pushing cholesterol up in the first place:

Supplements to consider

• Coenzyme Q10 or Ubiquinol (same thing)
• Niacinamide 500mg
• Resveratrol
• L arginine
• Berberine

Some non-medication treatments aim to stop fat from the diet being absorbed in the first place

• Cholestyramine improves the flow of a digestive juice called bile; thus means that more fats end up in the stool and out of the body
• Celery juice is an example of a plant compound which can boost bile flow but also prevent absorption of some of the dietary fats; green tea has a similar role

Finally, if all these measures are not enough and the LDL is high, your doctor may recommend a class of medications known as anti-lipids. These include the well known statins as well as fenofibrate and some more novel treatments.

How often should I have my cholesterol checked?

A healthy person might have their cholesterol checked every other year. If somebody is known to have risk factors such as smoking, a family history, metabolic disease or high blood pressure, it should be done regularly until treatments bring it to a healthy range.

What cholesterol should I aim for?

For somebody with risk factors, specialists recommend an LDL generally lower than 2.0 mmol/L.

For somebody who has had a stroke or heart attack, this might be even lower; listen to your specialist and work with them to achieve that.

For somebody without risk factors, it depends on the total situation. It is ideal to see the LDL at least lower than 3.5 mmol/L

References

Navab M, Ananthramaiah GM, Reddy ST, et al. The oxidation hypothesis of atherogenesis: the role of oxidized phospholipids and HDL. J Lipid Res. 2004;45(6):993-1007. doi:10.1194/jlr.R400001-JLR200

Parthasarathy S, Raghavamenon A, Garelnabi MO, Santanam N. Oxidized low-density lipoprotein. Methods Mol Biol

. 2010;610:403-417. doi:10.1007/978-1-60327-029-8_24

Poznyak AV, Nikiforov NG, Markin AM, et al. Overview of OxLDL and Its Impact on Cardiovascular Health: Focus on Atherosclerosis. Front Pharmacol

. 2021;11:613780. Published 2021 Jan 11. doi:10.3389/fphar.2020.613780

Steinberg D, Parthasarathy S, Carew TE, Khoo JC, Witztum JL. Beyond cholesterol. Modifications of low-density lipoprotein that increase its atherogenicity. N Engl J Med

. 1989;320(14):915-924. doi:10.1056/NEJM198904063201407