The Truth About Cholesterol

In the spirit of Valentine's Day, we wanted to explore a common heart health topic - cholesterol. There’s so much conflicting information on cholesterol and the risk of heart disease that we thought we’d do a deep dive, breaking down some of the myths and facts, and highlighting our functional approach to managing elevated levels. 

What is cholesterol? 

Cholesterol is a vital and complex molecule that plays a fundamental role in maintaining the structural integrity and functionality of every cell in the human body. Cholesterol serves as a building block for hormones, including sex hormones (estrogen and testosterone) and adrenal hormones (cortisol). Additionally, it’s a crucial component in the production of vitamin D, which is essential for bone health, mental health and immune function. 

While cholesterol is indispensable for various physiological processes, its levels are tightly regulated, and imbalances can lead to health issues. Contrary to what many of us think, not all cholesterol is harmful. There are different types of cholesterol, including low-density lipoprotein (LDL) and high-density lipoprotein (HDL), each with unique functions and variable risks. 

Understanding the intricate roles of cholesterol is essential for dispelling myths and promoting a nuanced approach to cardiovascular health. So, let’s dive into the truth about cholesterol. 

What does cholesterol do in your body? 

Cholesterol serves a multifaceted role in the body, participating in critical physiological functions. Different types of cholesterol play different roles - let’s break them down. 

1. Low-density lipoprotein cholesterol (LDL-C) is often labeled as "bad cholesterol" because its job is to carry cholesterol from the liver to the body’s cells, tissues and arteries. Thus, elevated levels can contribute to the formation of atherosclerotic plaques in arteries, increasing the risk of cardiovascular diseases. 

But not all LDL-C is the same. Within LDL-C, there are sub-particles like LDL-A and LDL-B. LDL-A is a large, fluffy particle that is relatively harmless since it isn’t oxidized by free radicals. Think about a big beach ball floating around your arteries. Because it’s big and bouncy, it doesn’t cause as much acute damage.

On the other hand, LDL-B is a smaller, denser particle that is more likely to become oxidized and adhere to the artery walls. This is what can increase atherosclerosis and heart disease risk. Fortunately, dietary and lifestyle changes can shift cholesterol patterns from excess LDL-B to more LDL-A. 

2. High-density lipoprotein (HDL), on the other hand, is commonly known as "good cholesterol" because it picks up excess cholesterol from the bloodstream and transports it to the liver for excretion. 

Understanding the intricacies of these cholesterol subparticles is essential for crafting a more thorough understanding of cholesterol and the associated risks.  

Where does cholesterol come from? 

Most of the cholesterol in our bodies is synthesized in the liver and only small amounts actually come from the food we eat. In fact, about 70-80% of total cholesterol production occurs in the liver and only the remaining 20-30% comes from dietary sources. The liver tightly regulates cholesterol synthesis, adjusting it based on the body's needs. 

The caveat to this is that some people are "hyper-responders" and exhibit a significant increase in blood cholesterol levels in response to dietary cholesterol intake. For these people, consuming foods high in cholesterol may lead to a more pronounced elevation in their blood lipid profile. This hyper-responsiveness varies among individuals and is influenced by genetic factors and overall metabolic health.

In short, the cholesterol we get from food has a far more modest impact on blood cholesterol levels than we were led to believe. A very small fraction of the population are sensitive to dietary cholesterol, while the rest of us are mostly affected by the cholesterol made in the liver. 

Is cholesterol really a problem? 

In and of itself, no. In fact, cholesterol is required for the proper functioning of every single cell in our body. But cholesterol can become a problem when it’s oxidized by free radicals.  

Free radicals are highly reactive molecules that can damage cells, tissues, and even DNA. They are produced as natural byproducts of various metabolic processes within the body, including energy production and immune responses. They become elevated in the presence of chronic inflammation and due to external factors like environmental pollutants, tobacco smoke, and ultra processed foods.   

In states of inflammation, an overabundance of free radicals oxidizes LDL cholesterol particles circulating in the bloodstream and turns them into a more atherogenic form. Ultimately, this is what contributes to the formation of arterial plaques. 

Inflammation and the oxidation of LDL cholesterol is the key factor in the progression of cardiovascular diseases, far more than the cholesterol itself. Addressing the sources of inflammation and mitigating exposure to free radicals is the key to preventing the adverse effects of cholesterol on cardiovascular health.  

Does high cholesterol cause heart disease? 

The relationship between cholesterol and heart disease is complex, and the understanding of it has evolved over the years.

To recap, cholesterol itself is not inherently harmful; rather,

it’s the interaction between inflammation and cholesterol that is associated with an increased risk and progression of heart disease. 

Recent research suggests that focusing solely on lowering cholesterol levels may not be sufficient. Instead, addressing the underlying causes of inflammation and promoting overall cardiovascular health through lifestyle interventions, such as a balanced diet, regular exercise, and stress management, is essential. Furthermore, individual responses to cholesterol vary, and some people may be more susceptible to the effects of elevated cholesterol levels than others.

Conventional vs. Functional Testing for Cholesterol 

Looking beyond conventional cholesterol testing is essential because it provides a more comprehensive view of an individual's cardiovascular health, considering factors beyond just total cholesterol and LDL-C levels. Functional testing explores additional parameters that contribute to heart disease risk and provides a more nuanced understanding of your metabolic and inflammatory status. 

Some tests to consider include:

• Particle Size and Number: Conventional testing often focuses on total cholesterol and LDL-C levels but may not distinguish between different particle sizes of LDL. Small, dense LDL particles (LDL-B) are more atherogenic than larger, buoyant ones (LDL-A). Functional testing can assess LDL particle size and number, providing a more accurate representation of cardiovascular risk.

• Triglyceride Levels: Elevated triglyceride levels are an important risk factor for heart disease.  

• Inflammation Markers: Chronic inflammation plays a significant role in the development of atherosclerosis. Functional testing evaluates markers of inflammation, such as high-sensitivity C-reactive protein (hs-CRP) and other inflammatory cytokines, providing insights into the inflammatory status of the cardiovascular system. 

• Insulin Resistance: Insulin resistance, often associated with metabolic syndrome and type 2 diabetes, is a risk factor for cardiovascular disease. Functional testing may include assessments of insulin sensitivity and glucose metabolism.

• Genetic Markers: Genetic factors can influence an individual's response to dietary and lifestyle interventions, as well as their predisposition to certain cardiovascular conditions. 

By incorporating these additional markers into functional testing, we can tailor interventions more precisely and offer a personalized and preventive approach to cardiovascular health.  

Statins and Their Side Effects 

Statins are a class of medications commonly prescribed to lower cholesterol levels and reduce the risk of cardiovascular events. While they can be effective for many individuals, they do have a wide range of adverse effects. The most common include: 

1. Coenzyme Q10 (CoQ10) Depletion: Statins inhibit the synthesis of CoQ10, a vital antioxidant and an essential component for cellular energy production. CoQ10 depletion may lead to muscle-related side effects, including weakness and fatigue.

2. Vitamin D Deficiency: Some studies suggest that statins may be associated with lower levels of vitamin D. Vitamin D is crucial for bone health, immune function, and overall well-being.

3. Vitamin K Depletion: Statins interfere with the vitamin K cycle, which is essential for blood clotting and bone metabolism. 

4. Muscle-Related Side Effects: Statins can cause muscle-related symptoms, ranging from mild muscle pain to more severe conditions like myopathy or rhabdomyolysis. CoQ10 depletion is thought to contribute to these effects.

5. Liver Enzyme Abnormalities: Statins can sometimes lead to elevated liver enzyme levels. Regular monitoring of liver function is typically recommended during statin therapy.

6. Cognitive Effects: Some individuals on statins report cognitive side effects, such as memory loss or confusion. However, the evidence on this is mixed, and more research is needed to establish a clear link.

7. Blood Sugar Levels: There is some evidence suggesting that statins may slightly

increase blood sugar levels, which is often a concern for individuals with elevated cholesterol.  

Stay tuned for part two of this article where we’ll dive into the functional approach to assessing and addressing cholesterol.