All you ever wanted to know about cholesterol (and more!)
Written by Dr Marissa Kelaher, graphics by Dr Taisia Cech
Confused about cholesterol? You're not the only one!
High cholesterol, and the health issues it causes, has a huge impact in our society - yet everywhere you look we're being told different conflicting messages…
Supplements, diets, detoxes, high fat vs low fat, dirty keto- you name it - no wonder its hard to know what to do!
But with heart disease being one of our greatest killers, its also super important to get the right advice. Fortunately when dig deeper and look at the science, and talk to the experts, it gets a bit clearer - with very consistent results and recommendations worldwide.
And lifestyle medicine can be incredibly effective at helping to lower both cholesterol and improve health, so let's take a deep dive and explore more 😊
Random fact - did you know that raised cholesterol isn't just linked to higher rates of heart disease - it also increases the risk of strokes, erectile dysfunction, Alzheimer's and even back pain and injuries 😳
And while most people believe that genetics are to blame, studies suggest that they only account for up up 10-20% of peoples total heart attack risk.
Meaning like with many things, lifestyle plays by far the biggest role in our heart health and cholesterol levels.
Cholesterol isn't just an issue as we age either - autopsies done on soldiers (often in their twenties or thirties) have shown that cholesterol plaques have often already started forming - plaques have even been found in kids as young as 11… meaning recommendations in countries like the USA suggest checking cholesterol from age 9 😬
Yet on the flip side, in parts of the world where people eat a whole food plant focused diet and stay active, heart disease and other cholesterol related issues are almost unheard of... which tells us just how powerful diet and lifestyle can be. We cover more on this in our Nutrition focus course and Reboot course
This means it's never too early to start being proactive!
SO WHAT IS CHOLESTEROL ANYWAY??
Cholesterol is a yellow waxy substance that is a type of fat, along with saturated fat, unsaturated fat, triglycerides and more. Its what is measured on a blood test for cholesterol, and it's used to help assess people's vascular risk, as research shows that cholesterol levels are directly related to our risk of heart attacks, strokes, and more.
Ie the worse our cholesterol readings are, the more likely we are to suffer these issues (although other factors such as high blood pressure, diabetes, insulin resistance, and metabolic syndrome also affect our risk).
While we often think of cholesterol as always being a bad thing, in reality it's also important for our health, as its part of our cell walls, nerve sheaths, and is needed to make sex hormones (ie oestrogen, testosterone), vitamin D, and bile acids (for digesting fat).
Yet on the flip side too much cholesterol is also not good for us - and our liver actually makes all we need - meaning we do not really need to eat it in our diets!
So like many things in life, it's about balance - we want enough cholesterol, but not too much- we'll cover why in the next section.
Another key factor with cholesterol is not just how much cholesterol we have in our blood, but also where we store it in our body. When cholesterol is inside our liver, it can be used for all the functions mentioned - but when it's blocking our arteries, it's not a good thing!
It's also worth noting that cholesterol is also ONLY found in animal products, explaining why people on plant based diets tend to have much lower levels of cholesterol overall, as well as lower rates of the health issues caused by cholesterol.
This is also part of why plant focused whole food diets (as we cover in our courses here and here) are recommended for heart and brain health by health experts worldwide!
We'll cover how different foods affect the cholesterol in our body in a minute, but first let's look at what makes cholesterol 'good' or 'bad'
ALL ABOUT GOOD AND BAD CHOLESTEROL
You may have had a cholesterol reading done, and been told about your ‘good’ and ‘bad’ cholesterol readings.
These are called HDL and LDL cholesterol (there are actually lots of subtypes within these groups, but this is too complex to cover here).
Did you know that the HDL and LDL that we measure aren't actually cholesterol themselves - they're what's called lipoproteins - carrier molecules that transport cholesterol around our body. As our blood is mostly water, and oil (fat) and water don't mix, so we need lipoproteins to help move cholesterol through our blood stream.
HDL (high density lipoprotein)
This is considered to be 'good' cholesterol, because it transports cholesterol molecules away from our artery walls and tissues, back to our liver, where it can be used. In simple terms, the HDL levels in our blood measure how much cholesterol is going to the right place!
HDL is highly protective against heart disease for this reason, so it's generally recommended to aim for as high a level as possible. We will explore how to increase your HDL soon.
LDL (low density lipoprotein)
In contrast, LDL is considered to be ‘bad’ cholesterol, as it does the opposite of HDL.
It transports cholesterol to where we don't want it - namely out to our artery walls, where it can build up and cause plaques and blockages, cutting off blood supply to where its needed (our heart, limbs, brain, organs, genitalia, and even our joints and spine).
This means higher levels of LDL = more cholesterol going where we don't want it to go
We DO need a small amount of LDL to transport cholesterol to other parts of our body (ie sex organs and skin, to make hormones and vitamin D) - but again the key is having enough, without having too much...
There is also an absolutely OVERWHELMING amount of research spanning many decades, that consistently shows that high levels of LDL = higher rates of heart disease and other cholesterol related diseases. This research also repeatedly shows that lowering LDL it is vital to improve the risks of these. And in the science world, multiple studies showing the same results means reproducibility - meaning the studies are highly likely to be correct, as they keep coming up with the same answers.
So despite what you may hear to the contrary, an LDL level that's within recommended ranges is an integral part of good health, and you don't want to ignore a raised level.
As we mentioned previously, addressing other heart risk factors (high blood pressure, diabetes /insulin resistance, and metabolic syndrome) is part improving heart health - but cholesterol is also just as important.
For the biggest benefits, you need to focus on them all!!
And fortunately the same lifestyle and diet that helps with cholesterol, tends to also help with blood pressure, insulin resistance, and metabolic syndrome, so you cover all your bases with some simple strategies - it’s what is called a ‘cardioprotective’ approach.
Interestingly, high LDL is also associated with higher rates of other diseases you wouldn't think of, such as osteoarthritis, autoimmune conditions, and even women's health issues. We don't know exactly why, but it's likely to be due to the fact that lifestyle changes that affect LDL, also affect these disease processes as well - or that there is a common underlying process contributing to all of them. And backing this up is strong research showing that the same simple lifestyle and nutrition approaches (which we teach in our courses), work well for all of these as well. Health doesn’t have to be complicated!
Targets for LDL levels depend on your overall heart disease risk - ranging from less than 1.4 for people who are very high risk (ie have known heart disease), to less than 2 for everyone else.
Its a good idea to talk to your doctor to discuss what level is recommended for you in the context of the rest of your health history.
And if you'd like to learn how to follow a cardioprotective diet and lifestyle, please check out our Nutrition and Reboot courses, where we teach the science behind these, and practical tips to make long lasting changes.
Triglycerides (TGL)
These are the other type of cholesterol that are measured on a standard cholesterol test, although what many people don't realise is that they're a bit different to HDL and LDL.
Triglycerides are also a type of fat, but rather than coming from fat in our diet, they actually come mostly from excess calories (in particular from added sugar, refined carbohydrates, and too much food in relation to activity levels, as well as alcohol.)
The role of triglycerides is mostly as an energy source, as they are made by the liver from excess energy from food we don’t immediately use up after eating a meal. Triglycerides travel through our bloodstream to supply energy to cells, and are stored in fat cells as an emergency store of energy (ie to use if we run out of food).
Think of them as a ‘deep freezer’ to store excess food - pretty clever, right?!.
When our cells need extra energy at a later time, triglycerides are released back into our blood as fatty acids, which fuel our muscles, create heat to keep us warm, and provide, energy for our cells - they're a crucial survival mechanism to prevent starvation in times of scarce food supplies.
Yet like with cholesterol, although we need a certain amount of TGL for energy, excess levels are extremely common in people who eat calorie dense western diets - and this isn't a good thing.
Again using the analogy of a deep freezer - if we put food in to store it, then take it out again later, the system works well, and keeps us healthy.
But if we keep filling up the freezer (our fat cells) with food, eventually it becomes too full (ie the fat cells can't store any more triglycerides), and it overflows into our bloodstream - showing up as raised triglyceride levels on a blood test.
If you have high fasting triglycerides, this is a very strong signal that your body is having trouble dealing with the amount of calories you are eating - which is why high triglycerides are also a sign of insulin resistance (the precursor to type 2 diabetes). Even high non fasting triglycerides are not a good sign.
In particular, the combination of high LDL, high triglycerides, low HDL, and elevated insulin levels /blood sugar, is considered to the 'highest risk' cholesterol pattern for heart attacks and strokes, as it indicates underlying metabolic syndrome.
Triglyceride:HDL (TG:HDL) ratio can also be calculated, it’s important as it is an important predictor of risk for heart disease.
TG:HDL ratio is a marker of insulin resistance, and insulin resistance is the major cause of prediabetes, metabolic syndrome, and type 2 diabetes (see our blog on insulin resistance here for more details)
TG:HDL ratio seems to be particularly important in women, and a study called The Women’s Ischemia Syndrome Evaluation (WISE) study found that TG:HDL ratio was one of the most powerful predictor of all mortality and cardiovascular events.
A lower TG/HDL is better, here are the reference ranges you can use to compare your own TG:HDL ratio to:
In US (mg/dL) – less than 2 is ideal; above 4 is too high
In Europe (mmol/L) – less than 0.87 is ideal; above 1.74 is too high
The main message, is that the overall pattern of your cholesterol results is just as important as the separate numbers!
High triglycerides can also be a marker of fatty liver disease, due to excess fat being stored in the liver (ie when our fat cells get too full). With this, liver function tests are slightly abnormal as well.
The main message here is - high triglycerides are not normal, so don’t ignore them!!
The best way to reduce your TGL is to stay active, avoid over eating, and reduce how many simple carbohydrates you eat (refined carbs, added sugar, and alcohol).
These strategies also help to reduce your risk of prediabetes, diabetes, and fatty liver disease, and can help to improve and even reverse these conditions, especially if detected early - so they are good ideas to follow all around!
We take a deep dive into cholesterol, fat, carbs and ways to optimise these in our courses here and here if you would like to discover more.
SO WHAT SHOULD MY CHOLESTEROL READING LOOK LIKE?
For the general public in New Zealand, recommended cholesterol targets are as follows:
Total cholesterol <4 mmol/L
LDL cholesterol <2 mmol/L
Triglycerides <1.7 mmol/L
HDL cholesterol >1 mmol/L
Total:HDL cholesterol ratio <4
Remember that cholesterol targets also depend on your overall health as well though - as we mentioned previously, LDL targets are lower (as low as 1.4 in some cases) if you have a history of heart disease or strokes, or have other health conditions that increase your cardiovascular risk.
So it's best to get a personalised cardiovascular risk assessment with your doctor to discuss what levels are healthy for you.
HOW EXACTLY DOES CHOLESTEROL AFFECT OUR HEALTH?
The answer lies in a process called atherosclerosis.
High bad cholesterol actually often starts causing problems decades before health issues are detected - its a slow burning disease...starting as early as age 20, or even in childhood in some people 😯
As we mentioned at the start of this blog post, when your LDL level gets too high, the LDL molecules start to transport cholesterol out to your blood vessels (arteries), where it gets deposited in the inner walls (endothelium) of your blood vessels - forming blockages called ''plaques'.
This process is called ''atherosclerosis''
Over time, this plaque can cause progressive narrowing of the artery, as the picture below shows.
This picture is a cross section of your artery, showing blood cells within it - the yellow stuff is the cholesterol building up in the walls, and eventually blocking the artery (from stage 1 - early plaque, to stage 3 - advanced disease)
Once the plaque has formed, it can cause problems in two different ways.
1) Thrombosis and a blocked artery:
Normally the cholesterol plaque is covered by a protective ‘cap’, which eventually hardens and becomes calcified. This is what tests such as CT calcium scores look at (the amount of calcified plaque in your heart arteries).
Stable plaque can cause gradual narrowing of the artery, but doesn't usually cause heart attacks or strokes - it’s our bodies way of trying to protect us against the cholesterol plaque.
However if the surface of the plaque becomes inflamed and cracks open, it releases chemicals that stimulate the formation of blood clots on the surface of the plaque ('thrombosis'), which can cause a sudden partial or total blockage in the artery.
When the artery gets blocked, it cuts off blood to the tissue it supplies, and causes that tissue to start dying (ischaemia)
✔️If this occurs in the arteries supplying the heart, it's called a heart attack.
✔️If it happens in the arteries that supply the brain, it's called a stroke.
✔️If it happens in the arteries supplying other areas of the body, it it causes ischaemia there (ie limb ischaemia in the arms or legs, mesenteric ischaemia in the gut, retinal artery occlusion in the eyes etc)
Whether or not the plaque cracks is related to a lot of factors, but we know that certain things make the lining of our blood vessels more 'sticky', ie more likely to form clots.
Inflammation is one factor - which is why anti inflammatory diets are now also encouraged to reduce cardiovascular risk, alongside reducing cholesterol. Levels of inflammation are what specialised cardiovascular tests such as hs-CRP measure.
Other factors that can affect the stickiness of the plaques include diabetes, hypertension, autoimmune diseases (ie rheumatoid arthritis, lupus, inflammatory bowel disease), smoking, obesity, high intake of saturated fat (from meat, eggs and dairy)/processed foods/ animal protein, sleep apnea, and hyper-homocystinemia.
These are therefore also considered to be risk factors for heart disease. Some we obviously have a degree of control over, others not so much - but with all of them, following an anti inflammatory eating pattern can often help!
We cover diet, inflammation, and how to eat an anti inflammatory diet in our Nutrition and Reboot courses if you'd like to learn more about these.
2) Gradual narrowing occurs.
In contrast, if the cholesterol plaque remains stable (ie doesn't crack open), rather than causing clots, it slowly builds up and narrows the inside of the artery. This leads to subtle yet progressively worsening symptoms, as less and less blood is able to get through to where its needed.
Stable plaques don't tend to cause as much damage as a clot, as they don't fully block off blood supply - instead they tend to cause symptoms when more blood needs to get through the artery, ie they cause symptoms when we exercise, that go away when we rest.
✔️If this gradual narrowing happens in the heart, we call it stable angina (chest pain during exercise, that is from lack of blood to the heart muscle, but doesn't cause a heart attack) .
✔️If it's in the legs, we call it peripheral vascular disease, which can cause leg pain while walking.
✔️If it's in the blood vessels supplying blood to the male genitalia, it can cause as erectile dysfunction (which can be a sign of narrowed arteries several years before other issues are detected) .
✔️If its in the arteries supplying the brain, it can cause vascular dementia (a common cause of dementia).
It’s can also cause back pain and disc prolapses, as the discs (shock absorbers) between our spinal bones also need blood to stay healthy - and can start to degenerate if they aren't getting enough.
You get the picture!!
So ideally, if we can prevent this happening in the first place, this is the best option.
Yet even when blockages have started to occur, lifestyle can make a massive difference - improving symptoms, reducing the risk of heart attacks and strokes, and even extending life expectancy - its never too late to change!!
Some studies have even shown that arteriosclerosis can be reversed with intensive lifestyle changes 😊
Research also shows that the concentration of LDL cholesterol circulating in your blood is directly related to your risk of atherosclerosis.
This means the higher your LDL = the greater the chance of a heart attack, stroke and erectile dysfunction.
This is also why doctors (especially cardiologists) tend to try to get LDL levels as low as possible, especially once artherosclerosis has been diagnosed.
Did you know, that every 1% you reduce your cholesterol, you decrease your risk of heart disease by 2%?!!
This means every little improvement counts - and the bigger the improvement the better!!
HOW CAN I IMPROVE MY CHOLESTEROL LEVELS?
This is where lifestyle medicine comes in!
Diet plays the biggest part but far, but exercise is also powerful at helping to improve cholesterol and cardiovascular risks.
Reducing LDL, increasing HDL, and to a lesser extent reducing inflammation, are all important aspects of reducing your heart disease risk.
Next let's look at each of these separately:
LDL CHOLESTEROL
The main foods that affect LDL cholesterol levels tend to come almost exclusively from animal products, and ultra-processed foods.
This is due to three types of fats found in these foods - saturated fats, trans fats and dietary cholesterol.
Eating these fats regularly in your diet can all increase your LDL cholesterol, as our liver converts them to LDL.
Yet contrary to intuitive thinking, dietary cholesterol (cholesterol naturally found in the foods you eat) isn't the main contributor of high blood levels of cholesterol - eating saturated fat is!.
SATURATED FAT is the fat found in fatty meats (ie red meat), full fat dairy, and eggs
Plants do not contain saturated fat (apart from some tropical oils, such as coconut and palm oil), so as a general rule, the more plants and the less animal products you eat, the lower your LDL will be.
Research shows that for every 1% of energy in our diet that comes from saturated fat, our LDL cholesterol will increase by 0.02–0.04 mmol/L.
There are some exceptions to this (ie people with genetic cholesterol disorders), but in general when you're thinking about lowering LDL cholesterol, the less animal foods, and more whole plant foods you eat, the better!
CHOLESTEROL is mostly found in animal foods, in particular in egg yolk, shrimp, beef, pork and poultry, as well as cheese and butter. As mentioned, it actually affects our LDL cholesterol less than saturated fat, although its still important to be aware of. Remember our body makes all the cholesterol we need - we don’t really need to eat it.
TRANS FATS are artificially created fats, made from hydrogenating vegetable oils. They are found mostly in highly processed foods, as they have a long shelf life and are very cheap to produce. Trans fats are also naturally contained in small amounts in meat and dairy.
Trans fats are highly inflammatory, and increase LDL as well as reducing HDL - they are actually WORSE than saturated fat for this reason, and banned in many countries due to their strong link with heart disease and other issues. Trans fats are labelled on foods as 'partially hydrogenated vegetable oil' - they are also completely unnecessary (ie we don't need them), so try avoid them completely if possible!!
So in general to reduce your LDL levels:
avoid foods that contain trans fats (ie processed foods that contain partially hydrogenated vegetable oil)
avoid or limit foods high in saturated fat (tropical oils, fatty or processed meat, cream, butter,
and regular cheese)aim for most of your dietary fat to come from monounsaturated fat (extra-virgin olive oil) and polyunsaturated fat
(non-tropical vegetable oils), as these reduce LDL and increase HDLtry to keep your saturated fat intake less than <10 % of your diet (<7% if your cholesterol is high)
Using the Mediterranean diet pyramid below is a good visual guide, as well as the wellness plate (both of these graphics are from our courses).
Wellness Plate
This is also the diet used in the PREDIMED and LYON heart trials - some of the largest ever trials looking at diet, cholesterol and heart disease.
✔️The LYON trial showed that heart attack patients who switched to a high fibre mostly plant based Mediterranean diet, reduced their risk of death by 60%, and their risk of further heart attacks by 70%, compared to people who continued to eat a typical Western diet!
✔️Whereas the PREDIMED study showed people who didn't already have heart disease, reduced their risk of future heart attacks by 30%, by eating a Mediterranean style diet plant focused supplemented with healthy fat (olive oil and nuts).
These results were purely from dietary changes - so when you add in other heart healthy habits such as regular exercise, limiting salt, not smoking, and managing stress/getting enough sleep, it can be a powerful combination for optimising your heart health!!
In addition to avoiding foods that increase LDL cholesterol, you can also lower LDL cholesterol by deliberately including foods in your diet proven to lower cholesterol.
Simply increasing your intake of soluble fiber for a start can significantly decrease your cholesterol level. Remember that fiber only exists in plant foods, like fruits, veggies, nuts, seeds, legumes and whole grains, so eating these on a daily basis is great for improving cholesterol levels (and overall heart health).
You can also consider a fiber supplement, but eating the whole food itself is obviously better where possible.
The foods proven to have the most powerful cholesterol lowering benefits are:
✔️Oats (note all whole grains can help reduce cholesterol due to their fibre content
✔️Legumes, such as chickpeas, navy beans, lentils
✔️Soy (shown to decrease cholesterol by up to 5%)
✔️Nuts (due to their healthy fat content)
Researchers have even developed a cholesterol specific diet - called the portfolio diet.
This diet intentionally includes food know to reduce cholesterol - such as oats, soy, fiber, plant sterols and nuts.
In particular, it specifies eating the following foods each day, in addition to the healthy eating picture we included above:
✔️ Soy protein: 50 grams per day (ideally unprocessed soy, ie tofu, edamame beans, miso)
✔️Plant sterols: 2 grams per day
✔️Nuts: 45 grams per day ie 1 handful, or about 23 almonds
✔️Soluble fiber: 18 grams per day (ie from oats, barley and other whole grains)
When used in combination, these foods also seem to have additive effects in lowering blood cholesterol (Jenkins et al., 2003). In one study, people who followed the portfolio diet, lowered their LDL levels by almost 30% - a similar effect to many statin medications!!!
And one large meta-analysis of the Portfolio Diet showed that it not only significantly reduces LDL-cholesterol, but also improved other cholesterol levels (non-HDL-cholesterol, apolipoprotein B, total-cholesterol and triglycerides), reduced blood pressure and inflammation, and reduced people's overall cardiovascular risk.
Ie it didn't just help cholesterol - it helped all the risk factors for heart health!!
So diet really can be powerful - and even if you need a statin medication, adding dietary changes will help further (plus improve the rest of your health too).
HDL CHOLESTEROL
You can also improve your HDL (good cholesterol) using the strategies described above.
Exercising regularly, not smoking, aiming for a healthy weight, increasing omega 3 in your diet (via plant based sources such as chia seeds, linseed, walnuts, and hemp hearts, or via oily fish) can also help increase your HDL levels and protect your heart and blood vessels
TO WRAP IT ALL UP
So what are our top tips to improve cholesterol and reduce your risk of health issues such as heart disease, strokes, dementia and more?!
Eat whole foods, mostly plants
Boost your fibre intake
Include plant foods with specific cholesterol lowering benefits, such as oats, soy, legumes, nuts and plant sterols in your diet regularly
Stay active, aiming to get moving every day if possible
Limit or avoid processed foods, foods with added sugar, and alcohol, and swap refined carbs for whole grains
Arm to use the Mediterranean diet patten and the wellness plate as a guide for how you eat
Limit how much saturated fat (aka animal products) you eat, especially if you have high cholesterol or other risks for heart disease
Plus try practice other habits to reduce inflammation and cardiovascular risk, such as eating an anti-inflammatory diet, avoiding cigarette smoke, limiting salt, and aiming for a healthy weight range if possible
Ie all the things we already advise for overall good health - it's simple!
And if you've found this interesting and want to know more, we cover all these topics and much much more in our Reboot and Nutrition courses - for a complete health transformation!!
Plus if you'd like personalised advice to help you reduce your cholesterol and heart disease risk, plus a practical evidence based plan to put it into action, we offer virtual lifestyle medicine consultations New Zealand wide (by secure telemedicine server) or in person (in Nelson only). We'd love to meet you and help you optimise your health and wellbeing! More details here
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https://academic.oup.com/eurheartj/article/41/1/111/5556353?login=false (European lipid guidelines)