Rethinking Cholesterol

We need to blow up our current thinking about cholesterol and start over.

Assumption 1

Atherosclerotic plaque that builds up in our arteries is full of cholesterol and fatty tissue, therefore high cholesterol levels in the blood must be a primary cause of that plaque.

Assumption 2

Foods high in cholesterol and fat (like eggs, shrimp, butter and nuts) raise blood cholesterol.

Assumption 3

Fatty foods make us fat.

Assumption 4

If we use pharmaceuticals (primarily statins like Lipitor, Zocor and Crestor) to lower cholesterol levels in the blood, then we must therefore reduce the amount of cholesterol-laden plaque in the arteries, that then reduces the risk of heart attack and stroke.

Reality Check 1

There are many causes of the atherosclerotic plaque that build up in a human being including smoking, diabetes, stress, hypertension, poor diet, obesity, lack of exercise, social isolation and genetic factors. I tell patients that cholesterol levels in the blood, in my opinion, probably rank somewhere between 8th and 10th on the list of risk factors. I have patients with low cholesterol levels but lots of plaque and others with sky high cholesterol levels with little or no plaque after 60+ years of living.

Reality Check 2/3

There are two major causes of elevated cholesterol levels in the blood: genetics and obesity. The genetics are not well understood as far as I can tell. The foods that tend to cause obesity are sugar and wheat-based carbohydrates. Those foods cause metabolic chaos leading to insulin resistance that results in extra sugar being stored as fat. The more fat (or adipose tissue) a person has, the higher the cholesterol levels in the blood.

Reality Check 4

Most medications, herbs and supplements that lower cholesterol levels in the blood have little or no impact on cardiovascular risk. The primary mechanism that statins lower risk is likely their anti-inflammatory effect, not their cholesterol-lowering effect.

Reality Check 5

Statins have value but there are many negatives as well. I suspect that many who take them have a relatively poor diet because they figure the medication is keeping their numbers down, so they’re protected. The most common side effect of statins is muscle pain. I also suspect there are many patients taking statins who have muscle pains that affect their tendency to exercise negating the benefit.

The Bottom Line

Elevated cholesterol levels should be put in the context of overall risk. It is often better to view them as a reflection of a poor lifestyle that needs to be changed rather than an independent risk factor that needs to be medicated.

Andrew Lenhardt, MD

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