Heart Disease and the Role of Cholesterol

Cholesterol has certainly gotten a bad rap over the years – remember the low fat craze where butter and eggs were considered ‘bad’ for vascular health? Fortunately, medical organizations have reversed their position on cholesterol but many of us are still not looking at the whole picture.

In an interesting podcast by Dr. Elizabeth Boham on the Doctor’s Farmacy, she discusses how cholesterol is only one factor in cardiovascular disease and in lieu of looking at cholesterol as a symptom of heart disease, we need a more comprehensive and balanced approach in considering all the risk factors. So in this two-part blog, I’ll highlight: 1) factors that contribute to heart disease and cholesterol’s role in it, and 2) natural ways to manage heart disease risk factors.

Cholesterol is critical for our body to function – it not only makes essential hormones to keep us alive but one quarter of the body’s cholesterol is in our brain so it’s what keeps us mentally sharp. In fact, several studies have demonstrated higher rates of dementia in people with low cholesterol.

Cholesterol is composed mainly of two types: high-density lipoprotein (HDL) and low-density lipo-protein (LDL). Lipoproteins are made of fats and proteins and they are the transport mechanism for cholesterol through your body.
- HDL transports excess fats and oxidized fats back to the liver for recycling and disposal.
- LDL carries cholesterol through the bloodstream along with fat-soluble vitamins (A, D, K) and essential fatty acids (DHA, EPA), so it is vital for our body to function. But too much of it can collect in arterial walls and lead to plaque buildup known as atherosclerosis.

It’s important to look at triglycerides as they are carried around in your blood by lipoproteins that make up cholesterol. Triglycerides are a type of fat in your blood. Oils and butters and fat are triglycerides but your body also turns excess calories and simple carbohydrates like breads, pasta, sugar and alcohol into triglycerides and stores them in fat cells. Triglycerides are essential to the body but in excess, can lead to obesity, diabetes and heart disease.

There is an association of cholesterol with vascular disease but we need to know what the numbers actually mean as the risk factors vary depending on the individual.

75% of patients with heart attacks have normal ranges of cholesterol. However, what’s interesting is that two thirds of patients with heart attacks have either pre-diabetes or diabetes which are un-diagnosed and un-tested.

The problem with standard cholesterol testing is that it only gives you the number with no idea how large the particles are. The cholesterol test you should ask your doctor about is particle size testing. It is called the NMR panel (LabCorp) or Cardio IQ (Quest) – it should be covered by insurance. I had mine done about five years ago and it was covered.

Size matters! The analogy used to describe cholesterol and particle size was dirt and dump trucks. Cholesterol is the dirt and dump trucks are the particles carrying the cholesterol. What’s desired are big dump trucks (big particle size) to move the cholesterol. Having too many small dump trucks (small particle size) is concerning as this can cause plaque build-up and lead to heart disease.

In one patient with a cholesterol of 300, LDL 150 and HDL 110, particle size testing showed that the patient had large fluffy particles (big dump trucks) so the doctor was not so concerned about the heart disease risk in spite of the cholesterol numbers.

There is a genetic component – obviously, if you have a strong family history of heart disease, you need to be more careful. But for most of us, it is lifestyle, lifestyle, lifestyle. Insulin resistance is the key driver in heart disease – 88% of Americans have metabolic inflexibility and 50% have pre-diabetes/diabetes, many combined with excess weight. People with metabolic syndrome and insulin resistance typically have higher triglycerides, lower HDL and more small particle LDL.

One easy way to determine if you have insulin resistance is your triglyceride/HDL ratio. Ideally, your ratio should be below 1. If you are above 1, you should talk to your doctor about getting fasting insulin and other diabetes markers tested.

Diet is the key lifestyle component – the Standard American Diet is loaded with white processed carbs and sugar leading to insulin resistance, high triglycerides and high small particle LDL.

A whole foods-based, low sugar diet with lots of fiber, good fats, B vitamins, folate, fish oil combined with a vigorous exercise program should be a priority for those wanting to improve their heart disease markers.

Inflammation and oxidative stress cause heart disease. Belly fat and/or visceral fat secretes inflammatory markers and leads to oxidative stress. The LDL particles get oxidized due to the excessive free radicals and not enough antioxidants to neutralize them. The oxidized LDL particles cause plaque build-up. So to understand heart disease risk, it’s not just about the LDL number but the level of inflammation in the body that causes oxidation of these particles.

Statins are a powerful anti-inflammatory drug so it can help, but as it comes with side effects there are more natural ways to reduce inflammation in the body.

There are also special tests to measure oxidative stress – most likely you will need to see an integrative or functional medicine doctor to get these ordered.

There are other factors besides inflammation and cholesterol that affect vascular health and they include: diet, smoking status, calcium and homocysteine levels, vitamin and nutrient status, toxins and pollution, oral health (like gingivitis) and your gut microbiome.