Why Cholesterol May Not Be the Cause Of Heart Disease

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WE HAVE ALL BEEN LED TO to believe that cholesterol is bad and that lowering it is good. Because of extensive pharmaceutical marketing to both doctors and patients we think that using statin drugs is proven to work to lower the risk of heart attacks and death.

But on what scientific evidence is this based, what does that evidence really show?

Roger Williams once said something that is very applicable to how we commonly view the benefits of statins. “There are liars, damn liars, and statisticians.”

We see prominent ads on television and in medical journals — things like 36% reduction in risk of having a heart attack. But we don’t look at the fine print. What does that REALLY mean and how does it affect decisions about who should really be using these drugs.

Before I explain that, here are some thought provoking findings to ponder.

  • If you lower bad cholesterol (LDL) but have a low HDL (good cholesterol) there is no benefit to statins. (i)
  • If you lower bad cholesterol (LDL) but don’t reduce inflammation (marked by a test called C-reactive protein), there is no benefit to statins. (ii)
  • If you are a healthy woman with high cholesterol, there is no proof that taking statins reduces your risk of heart attack or death. (iii)
  • If you are a man or a woman over 69 years old with high cholesterol, there is no proof that taking statins reduces your risk of heart attack or death. (iv)
  • Aggressive cholesterol treatment with two medications (Zocor and Zetia) lowered cholesterol much more than one drug alone, but led to more plaque build up in the arties and no fewer heart attacks. (v)
  • 75% of people who have heart attacks have normal cholesterol
  • Older patients with lower cholesterol have higher risks of death than those with higher cholesterol. (vi)
  • Countries with higher average cholesterol than Americans such as the Swiss or Spanish have less heart disease.
  • Recent evidence shows that it is likely statins’ ability to lower inflammation it what accounts for the benefits of statins, not their ability to lower cholesterol.

So for whom do the statin drugs work for anyway? They work for people who have already had heart attacks to prevent more heart attacks or death. And they work slightly for middle-aged men who have many risk factors for heart disease like high blood pressure, obesity, or diabetes.

So why did the 2004 National Cholesterol Education Program guidelines expand the previous guidelines to recommend that more people take statins (from 13 million to 40 million) and that people who don’t have heart disease should take them to prevent heart disease. Could it have been that 8 of the 9 experts on the panel who developed these guidelines had financial ties to the drug industry? Thirty-four other non-industry affiliated experts sent a petition to protest the recommendations to the National Institutes of Health saying the evidence was weak. It was like having a fox guard the chicken coop.

People with the lowest cholesterol as they age are in fact at highest risk of death. Under certain circumstances, higher cholesterol can actually help increase life span.

It’s all in the spin. The spin of the statistics and numbers. And it’s easy to get confused. Let me try to clear things up.

When you look under the hood of the research data you find that the touted “36% reduction” means a reduction of the number of people getting heart attacks or death from 3% to 2% (or about 30-40%).

And that data also shows that treatment only really works if you have heart disease already. In those who DON’T have documented heart disease, there is no benefit.

In those at high risk for heart disease about 50 people would need to be treated for 5 years to reduce one cardiovascular event. Just to put that in perspective: If a drug works, it has a very low NTT (number needed to treat). For example, if you have a urine infection and take an antibiotic, you will get near a 100% benefit. The number needed to treat is “1″. So if you have an NTT of 50 like statins do for preventing heart disease in 75% of the people who take them, it is basically a crap shoot.

Yet at a cost of over $28 billion a year, 75% of all statin prescriptions are for exactly this type of unproven primary prevention. Simply applying the science over 10 years would save over $200 billion. This is just one example of reimbursed but unproven care. We need not only prevent disease but also prevent the wrong type of care.

If these medications were without side effects, then you may be able to justify the risk – but they cause muscle damage, sexual dysfunction, liver and nerve damage and other problems in 10-15% of patients who take them. Certainly not a free ride.

So if lowering cholesterol is not the great panacea that we thought, how do we treat heart disease, and how do we get the right kind of cholesterol – high HDL, low LDL and low triglycerides and have cholesterol particles that are large, light and fluffy rather than small, dense and hard, which is the type that actually causes heart disease and plaque build up.

We know what causes the damaging small cholesterol particles. And it isn’t fat in the diet. It is sugar. Sugar in any form or refined carbohydrates (white food) drives the good cholesterol down, cause triglycerides to go up, creates small damaging cholesterol particles, and causes metabolic syndrome or pre-diabetes. That is the true cause of most heart attacks, NOT LDL cholesterol.

One of the reasons we don’t hear about this is because there is no good drug to raise HDL. Statin drugs lower LDL — and billions are spent advertising them, even though they are the wrong treatment.

If you’re like most of the patients I see in my practice, you’re convinced that cholesterol is the evil that causes heart disease. You may hope that if you monitor your cholesterol levels and avoid the foods that are purported to raise cholesterol, you’ll be safe from America’s number-one killer.

We are all terrified of cholesterol because for years well-meaning doctors, echoed by the media, have emphasized what they long believed is the intimate link between cholesterol and death by heart disease. If only it were so simple!

The truth is much more complex.

Cholesterol is only one factor of many — and not even the most important — that contribute to your risk of getting heart disease.

First of all, let’s take a look at what cholesterol actually is. It’s a fatty substance produced by the liver that is used to help perform thousands of bodily functions. The body uses it to help build your cell membranes, the covering of your nerve sheaths, and much of your brain. It’s a key building block for our hormone production, and without it you would not be able to maintain adequate levels of testosterone, estrogen, progesterone and cortisol.

So if you think cholesterol is the enemy, think again. Without cholesterol, you would die.

In fact, people with the lowest cholesterol as they age are at highest risk of death. Under certain circumstances, higher cholesterol can actually help to increase life span.

In reality, the biggest source of abnormal cholesterol is not fat at all — it’s sugar. The sugar you consume converts to fat in your body. And the worst culprit of all is high fructose corn syrup.

To help clear the confusion, I will review many of the cholesterol myths our culture labors under and explain what the real factors are that lead to cardiovascular disease.

Cholesterol Myths

One of the biggest cholesterol myths out there has to do with dietary fat. Although most of us have been taught that a high-fat diet causes cholesterol problems, this isn’t entirely true. Here’s why: The type of fat that you eat is more important than the amount of fat. Trans fats or hydrogenated fats and saturated fats promote abnormal cholesterol, whereas omega-3 fats and monounsaturated fats actually improve the type and quantity of the cholesterol your body produces.

In reality, the biggest source of abnormal cholesterol is not fat at all — it’s sugar. The sugar you consume converts to fat in your body. And the worst culprit of all is high fructose corn syrup.

Consumption of high fructose corn syrup, which is present in sodas, many juices, and most processed foods, is the primary nutritional cause of most of the cholesterol issues we doctors see in our patients.

So the real concern isn’t the amount of cholesterol you have, but the type of fats and sugar and refined carbohydrates in your diet that lead to abnormal cholesterol production.

Of course, many health-conscious people today know that total cholesterol is not as critical as the following:

  • Your levels of HDL “good” cholesterol vs. LDL “bad” cholesterol
  • Your triglyceride levels
  • Your ratio of triglycerides to HDL
  • Your ratio of total cholesterol to HDL

Many are also aware that there are different sizes of cholesterol particles. There are small and large particles of LDL, HDL, and triglycerides. The most dangerous are the small, dense particles that act like BB pellets, easily penetrating your arteries. Large, fluffy cholesterol particles are practically harmless–even if your total cholesterol is high. They function like beach balls and bounce off the arteries, causing no harm.

Another concern is whether or not your cholesterol is rancid. If so, the risk of arterial plaque is real.

Rancid or oxidized cholesterol results from oxidative stress and free radicals, which trigger a vicious cycle of inflammation and fat or plaque deposition under the artery walls. That is the real danger: When small dense LDL particles are oxidized they become dangerous and start the build up of plaque or cholesterol deposits in your arteries.

Now that we’ve explored when and how cholesterol becomes more problematic, let’s take a look at other factors that play a more significant role in cardiovascular disease.

Prime Contributors to Cardiovascular Disease

First of all, cardiovascular illness results when key bodily functions go awry, causing inflammation, (vii) imbalances in blood sugar and insulin and oxidative stress.

To control these key biological functions and keep them in balance, you need to look at your overall health as well as your genetic predispositions, as these underlie the types of diseases you’re most likely to develop. It is the interaction of your genes, lifestyle, and environment that ultimately determines your risks — and the outcome of your life.

This is the science of nutrigenomics, or how food acts as information to stall or totally prevent some predisposed disease risks by turning on the right gene messages with our diet and lifestyle choices. That means some of the factors that unbalance bodily health are under your control, or could be.

These include diet, nutritional status, stress levels, and activity levels. Key tests can reveal problems with a person’s blood sugar and insulin, inflammation level, level of folic acid, clotting factors, hormones, and other bodily systems that affect your risk of cardiovascular disease.

Particularly important are the causes if inflammation, which are many, and need to be assessed. Inflammation can arise from poor diet (too much sugar and trans and saturated fats), a sedentary lifestyle, stress, autoimmune disease, food allergies, hidden infections such as gum disease, and even toxins such as mercury. All of these causal factors need to be considered anytime there is inflammation.

Combined together, all of these factors determine your risk of heart disease. And I recommend that people undergo a comprehensive medical evaluation to see what their risk really is.

Zeroing in on Key Factors for Heart Disease

There’s no doubt about it, inflammation is key contributor to heart disease. A major study done at Harvard found that people with high levels of a marker called C-reactive protein (CRP) had higher risks of heart disease than people with high cholesterol. Normal cholesterol levels were NOT protective to those with high CRP. The risks were greatest for those with high levels of both CRP and cholesterol.

Another predisposing factor to heart disease is insulin resistance or metabolic syndrome, which leads to an imbalance in the blood sugar and high levels of insulin. This may affect as many as half of Americans over age 65. Many younger people also have this condition, which is sometimes called pre-diabetes.

Although modern medicine sometimes loses sight of the interconnectedness of all our bodily systems, blood sugar imbalances like these impact your cholesterol levels too. If you have any of these conditions, they will cause your good cholesterol to go down, while your triglycerides rise, which further increases inflammation and oxidative stress. All of these fluctuations contribute to blood thickening, clotting, and other malfunctions — leading to cardiovascular disease.

What’s more, elevated levels of a substance called homocysteine (which is related to your body’s levels of folic acid and vitamins B6 and B12) appears to correlate to cardiovascular illness. Although this is still somewhat controversial, I often see this inter-relationship in my practice. While genes may play a part, tests done as part of a comprehensive evaluation of cardiac risk can easily ascertain this factor. Where problematic levels occur, they can be easily addressed by adequate folic acid intake, along with vitamins B6 and B12.

Testing for Cardiovascular Risk Factors

Heart disease is not only about cholesterol. It is important to look at many factors that contribute to your overall risk. And it seems that insulin and blood sugar imbalances, and inflammation are proving to be more of a risk that cholesterol.

If you want to test your overall risk, you can consider asking your doctor to perform the following tests:

  1. Total cholesterol, HDL cholesterol, LDL cholesterol, and triglycerides. Your total cholesterol should be under 200. Your triglycerides should be under 100. Your HDL should be over 60. Your LDL should be ideally under 80. Your ratio of total cholesterol to HDL should be less than 3.0. Your ratio of triglycerides to HDL should be no greater than 4, which can indicate insulin resistance if elevated.
  2. NMR Lipid Profile. This looks at your cholesterol under an MRI scan to assess the size of the particles, which can determine your cardiovascular risk. This is a very important test that can further differentiate the risk of your cholesterol and can be an important factor to track as your system improves and your cholesterol transforms from being small dense and dangerous to light and fluffy and innocuous. It is done by a company called Liposcience and is also available through LabCorp.
  3. Glucose Insulin Tolerance Test. Measurements of fasting and 1 and 2 hour levels of glucose AND insulin helps identify pre-diabetes and excessively high levels of insulin, and even diabetes. Most doctors just check blood sugar and NOT insulin, which is the first thing to go up. By the time your blood sugar goes up, the train has left the station.
  4. Hemaglobin A1c. This measures your average blood sugar level over the last 6 weeks. Anything over 5.5 is high.
  5. Cardio C-reactive protein. This is a marker of inflammation in the body that is essential to understand in the context of overall risk. Your C-reactive protein level should be less than 1.
  6. Homocysteine. Your homocysteine measures your folate status and should be between 6 and 8.
  7. Lipid peroxides or TBARS test, which looks at the amount of oxidized or rancid fat. This should be within normal limits of the test and indicates whether or not you have oxidized cholesterol.
  8. Fibrinogen, which is another test looking at clotting in the blood. It should be less than 300.
  9. Lipoprotein (a), which is another factor that can promote the risk of heart disease, often in men. It should be less than 30.
  10. Genes or SNPs may also be useful in terms of assessing your situation. A number of key genes regulate cholesterol and metabolism, including Apo E genes and the cholesterol ester transfer protein gene. The MTHFR gene, which regulates homocysteine is also important and may be part of an overall workup.
  11. Get a high-speed CT or (EBT) scan of the heart if you are concerned that you have cardiovascular disease. This may be helpful to assess overall plaque burden and calcium score. A score higher than 100 is a concern, and a score higher than 400 indicates severe risk of cardiovascular disease.

Next I will review how to lower your risk of heart disease and fix your cholesterol. We’ll do this not by lowering the LDL, but by getting more light and fluffy LDL particles, which are protective and more HDL cholesterol, which is THE most important cholesterol.

Now I’d like to hear from you…

Have you been told that you need to lower your cholesterol?

If so, what were your told to do and how does that compare to what you’ve read here?

Does any of what you’ve read here come as a surprise?

Please share your thoughts by adding a comment below.

References

(i) Barter P, Gotto AM, LaRosa JC, Maroni J, Szarek M, Grundy SM, Kastelein JJ, Bittner V, Fruchart JC; Treating to New Targets Investigators. HDL cholesterol, very low levels of LDL cholesterol, and cardiovascular events. N Engl J Med. 2007 Sep 27;357(13):1301-10.

(ii) Ridker PM, Danielson E, Fonseca FA, Genest J, Gotto AM Jr, Kastelein JJ, Koenig W, Libby P, Lorenzatti AJ, MacFadyen JG, Nordestgaard BG, Shepherd J, Willerson JT, Glynn RJ; JUPITER Study Group. Rosuvastatin to prevent vascular events in men and women with elevated C-reactive protein. N Engl J Med. 2008 Nov 20;359(21):2195-207.

(iii) Abramson J, Wright JM. Are lipid-lowering guidelines evidence-based? Lancet. 2007 Jan 20;369(9557):168-9

(iv) IBID

(v) Brown BG, Taylor AJ Does ENHANCE Diminish Confidence in Lowering LDL or in Ezetimibe? Engl J Med 358:1504, April 3, 2008 Editorial

(vi) Schatz IJ, Masaki K, Yano K, Chen R, Rodriguez BL, Curb JD. Cholesterol and all-cause mortality in elderly people from the Honolulu Heart Program: a cohort study. Lancet. 2001 Aug 4;358(9279):351-5.

(vii) Hansson GK Inflammation, Atherosclerosis, and Coronary Artery Disease N Engl J Med 352:1685, April 21, 2005

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13 Responses to Why Cholesterol May Not Be the Cause Of Heart Disease

  1. Lorraine Measor March 18, 2013 at 1:25 pm #

    I was told I had normal to high cholestoral, triglicerides, …..in other words metabolic syndrome. The doc put me on
    Lipiddil to lower the cholestoral and triglicerides…..and now I have another Doc. who has me on Lipitor only for
    the cholestorals. Its all so very confusing after reading your article!! Would these drugs be causing me to have bursitis in my thighs and cannot walk long distances?? Cannot decide wether to stay on drugs or get off of them . My father died of heart attack at age 59 and I just turned 67. HELP!!!!

    • Avatar of HymanStaff
      HymanStaff March 26, 2013 at 1:17 pm #

      Hello Lorraine,

      Thank you for your message and your interest in Dr. Hyman’s work. Your question and constellation of symptoms represents a complex medical condition. Questions regarding conditions like these cannot be answered in a responsible manner via the Internet.

      Wishing You the Best of Health!

      Dr. Hyman Staff

  2. DonB March 24, 2013 at 6:59 pm #

    This otherwise excellent article makes the unqualified statement that “saturated fats promote abnormal cholesterol” – which is wrong. Saturated long chain fats do, but saturated medium chain fats do not. The latter are found in in abundance in tropical fruit oils: coconut, palm and palm fruit. Diets high in tropical oils improve cholesterol profiles and populations who traditionally consume large amounts of these oils have had nil cardiovascular disease.

    Also, the article mentions “rancid” cholesterol, but does not mention the role of ingestion of polyunsaturated fats – which are very easily oxidized (aka rancid) in storage, heating and in the body. This is a crucial issue because arterial plaque is oxidized material.

    The list of tests is excellent. The NMR Lipid Profile in #2 above is also known as a VAP or high sensitivity cholesterol test – both yield particle size and buoyancy.

  3. Mary Lou Haugh April 21, 2013 at 11:50 pm #

    Why do you not let us print out this material? I would like to share it with friends and relatives. It is very good information . I would even like to show it to my doctor, who believes statins are the cure for colesteral. Also, it is more comfortable to read this on my easy chair, instead of ifrom the computer. Thank you so very much. Thank you. Mary Lou Haugh

    • Avatar of Dr. Hyman Nutrition Staff
      Dr. Hyman Nutrition Staff August 2, 2013 at 12:34 pm #

      Dear Mary Lou,

      Thank you for the great tip! You already have the ability to print the articles from your browser as an FYI!

      For more personalized nutrition advice, Dr Hyman’s nutrition coaching team would be happy to work with you on an individual level to help you reach your goals. To work with the nutrition coaching team please go to:http://www.bloodsugarsolution.com/nutrition-coaching/ OR call (800) 892-1443 to get started.
      In Good Health,
      The Nutrition Team

  4. Lenie April 22, 2013 at 2:42 am #

    In 2012 I must have had a small infarct although the cardiologist said 6 months later no that was not the case. I was hospitalized with a severe pain in my stomach area. Only went away with morfine. In three days they could not find anything wrong (after a lot of testing) but the crp in my blood flew sky high. No infections found, no temperature, nothing. I left hospital when the pain was gone and two weeks later the crp level was back to normal!!
    I now have iRBBB which I did not have before. All other blood levels were within the norm.
    All the treatment I get now is through an Orthomolecular Therapist and that helps tremendously. He showed me the book “Functional medicine”by dr. Hyman. I already had a quite good diet and am a slim, tiny built person, but now I also take some supplements and feel a lot better and have more energy. I think you are doing great work and I follow all this from the Netherlands.

  5. Michael Massa November 28, 2013 at 10:35 am #

    I have had total cholesterol and LDL cholesterol consistently out of the range that is now considered normal. However, all other factors are excellent. I am 62 years old. I am fit, I am thin, and I work out almost every day. I have an almost perfect diet, eating almost exclusively all natural whole foods and avoiding read meat and other sources of saturated fat. I have normal blood pressure. We do not have heart disease in the family.

    The details regarding cholesterol are as follows: my total cholesterol varies between 215 and 245 averaging about 225, my HDL cholesterol varies between 61 and 79 averaging about 68, my LDL varies between 135 and 170 averaging about 154, and my triglycerides vary between 42 and 52 averaging 47.

    My doctor has been more and more insistent over the last few years that I start on statins and I really don’t want to because of articles that I have read like this one. The situation with him has become very uncomfortable and I feel as though I should stop seeing him. I am considering going to a cardiology group to find out the condition of my arteries.

    I would very much appreciate any suggestions.

    Thank you.

  6. Liliana Dodge December 4, 2013 at 2:21 pm #

    My internist ordered the particle test from liposcience because my total cholesterol is at 230, my ldl at 140 and my hdl at 86. My triglycerides are normal, my reactive protein is low and my sugar is in normal levels, although he never ordered the insulin test, only the sugar in blood. The particles came back small and dense, suggesting a borderline high risk.

    I have a tendency toward higher blood pressure, I take 25 mg of atenolol daily. My cardiologist thinks it is mostly secondary in origin, caused by anxiety. I have narrow angle glaucoma, and I treat that with drops of pilocarpine, 1 mg. daily in each eye.

    How can I transform my small dense particles into large fluffy ones? I would highly appreciate your recommendations.

    • Avatar of Team Hyman
      Team Hyman December 27, 2013 at 2:58 pm #

      Thank you for your interest In Dr. Hyman’s work. Unfortunately he cannot provide you personalized medical advice in this forum. In order to provide you the proper care you need we hope you will seek the attention of a local qualified Functional Med practitioner soon. To locate a doctor near you who practices functional medicine like Dr. Hyman, go to http://www.functionalmedicine.org/practitioner_search.aspx?id=117 and scroll down to where it says “locate a practitioner” and enter your location. Progress accordingly from there.
      You can also make an appointment to be a patient at Dr.Hyman’s UltraWellness Center in Lenox, MA. Please go to: http://www.ultrawellnesscenter.com/becoming-a-patient/
      Did you know you can work with Dr. Hyman’s nutritionists virtually? For personalized nutrition coaching, please see: http://store.drhyman.com/Store/List/Coaching-Programs
      In Good Health,
      Dr. Hyman’s Wellness Staff

  7. judy gretzula December 14, 2013 at 10:42 am #

    Hi, I recently turned 60 with no major health issues (aside from an elective ablation last year for repeated episodes of SVT). For the past year, job changes, decreased sleep, weight gain, and increased personal stress have caused me to abandon my previous healthy lifestyle. A few months ago, I had an episode of chest pain which, combined with the past year’s unhealthy lifestyle, caused me to believe I was having a heart attack. I was hospitalized overnight and had cardiac cath the next morning (stress test one year ago prior to ablation was normal). Cath was completely normal, but my labs were not so good. Total cholesterol was 256, HDL 59, LDL 171, and triglycerides were 117. Both parents are still alive…..mother has no hx of heart disease, but is diet controlled for type 2 diabetes (maternal grandmother also had type 2). Father is alive (90), diagnosed 10 years ago with CAD, but otherwise in good shape. My PCP is insistent I go on Lipitor….even though my cath was normal, I should “keep it that way”, according to him. I am resistant, and have vowed to resume my previously healthy lifestyle.Whether or not a big “drop” in my overall numbers occurs is fine by me, but not with him.. What is your opinion, given my individual circumstances???

    • Avatar of Team Hyman
      Team Hyman December 27, 2013 at 2:17 pm #

      Thank you for your interest In Dr. Hyman’s work. Unfortunately he cannot provide you personalized medical advice in this forum. In order to provide you the proper care you need we hope you will seek the attention of a local qualified Functional Med practitioner soon. To locate a doctor near you who practices functional medicine like Dr. Hyman, go to http://www.functionalmedicine.org/practitioner_search.aspx?id=117 and scroll down to where it says “locate a practitioner” and enter your location. Progress accordingly from there.
      You can also make an appointment to be a patient at Dr.Hyman’s UltraWellness Center in Lenox, MA. Please go to: http://www.ultrawellnesscenter.com/becoming-a-patient/
      Did you know you can work with Dr. Hyman’s nutritionists virtually? For personalized nutrition coaching, please see: http://store.drhyman.com/Store/List/Coaching-Programs
      In Good Health,
      Dr. Hyman’s Wellness Staff

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