My Cholesterol

I recently had my blood work tested for my annual physical and discovered that my cholesterol levels are elevated. I started looking into what this exactly means and what to do about it. Here is a table of my last three results:

Date Total
Cholesterol
HDL LDL Triglycerides
Apr-15 222 53 152 86
Aug-16 208 56 139 64
Apr-18 234 57 169 41

All my other results are within normal ranges, i.e., liver function, blood sugar, electrolyte balance. So the only concern is with my blood cholesterol levels. Only having three years of results is somewhat limited, however it does paint a picture and establish a trend.

What is cholesterol?

WebMD defines cholesterol as a “waxy, fat-like substance made in the liver and found in certain foods from animals, such as dairy products, eggs, and meat. The body needs some cholesterol in order to function properly.”

Cholesterol is a sterol which is a type of lipid (fat) molecule. Approximately 80-90% of blood cholesterol levels is created by the body. It is essential to all animal life, because it is a maintains both structural integrity and liquidity of cell membranes. Each cell has the ability to synthesize cholesterol. It’s also a precursor to steroid hormones (testosterone, estrogen & progesterone), it gets oxidized in the liver resulting in several bile acids, the adrenal gland hormones cortisol & aldosterone and when the body is exposed to UV rays, it is converted into vitamin D.

Dietary cholesterol is actually poorly absorbed in the body, a 2011 study published in the British Journal of Nutrition discovered that “Dietary cholesterol content does not significantly influence plasma cholesterol values, which are regulated by different genetic and nutritional factors that influence cholesterol absorption or synthesis. Some subjects are hyper-absorbers and others are hyper-responders, which implies new therapeutic issues. Epidemiological data do not support a link between dietary cholesterol and CVD.” Which adds to the evidence suggesting that eating a diet high in cholesterol doesn’t affect blood cholesterol levels.

Cholesterol is generally broken down into High Density Lipoproteins (HDL), Low Density Lipoproteins (LDL) and Very Low Density Lipoproteins (VLDL). The easy way to interpret blood work, is to think you want the HDL high and the LDL low and VLDL as low as possible.

hdl-ldl
Source: https://www.epainassist.com/blood-diseases/hdl-vs-ldl-differences-worth-knowing

HDL is thought of as the ‘good’ type of cholesterol, as it helps keep cholesterol from the arteries and removes arterial plaque.

LDL is the ‘bad’ cholesterol and conventional wisdom holds that it can build up in arteries, form plaque and leads to atherosclerosis and forming clots.

Another measurement taken during the blood test is your triglyceride levels. Triglycerides are another type of lipid that circulates in the body. It is different to cholesterol and are created when excessive calories are consumed as a store in the body’s fat cells. They are used to build cells and hormones. Some studies highlight elevated triglycerides level being a statistically significant risk factor when identifying possible coronary disease. Elevated triglyceride levels alone are generally asymptomatic and are usually accompanied with other symptoms or conditions.

What are healthy levels of cholesterol?

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Some controversy starts to appear when we start to dig deeper into what direct health implications blood cholesterol levels actually have on the body. There are a lot of caveats to some of the research I have found across the internet. A big underlying notion underpinning the theses is that statin lowering drugs are effective at lowering cholesterol, but they aren’t effective in lowering the chances of cardiovascular disease. The other factor to consider is that it’s not possible to base a person’s level of overall health, solely on a single number or ratio. A wholistic view of any person must be taken into account.

One study that spanned 23 statin treatment arms with 309,506 people over several years from the Journal of American College of Cardiology found that the “Risk of statin-associated elevated liver enzymes or rhabdomyolysis is not related to the magnitude of LDL-C lowering. However, the risk of cancer is significantly associated with lower achieved LDL-C levels. These findings suggest that drug- and dose-specific effects are more important determinants of liver and muscle toxicity than magnitude of LDL-C lowering. Furthermore, the cardiovascular benefits of low achieved levels of LDL-C may in part be offset by an increased risk of cancer.”

A recent study published in The BMJ Open concluded that, “High LDL-C is inversely associated with mortality in most people over 60 years. This finding is inconsistent with the cholesterol hypothesis (ie, that cholesterol, particularly LDL-C, is inherently atherogenic). Since elderly people with high LDL-C live as long or longer than those with low LDL-C, our analysis provides reason to question the validity of the cholesterol hypothesis. Moreover, our study provides the rationale for a re-evaluation of guidelines recommending pharmacological reduction of LDL-C in the elderly as a component of cardiovascular disease prevention strategies”

There are several issues with the above studies pointed out by experts in the field, who currently believe that high cholesterol should be addressed and possibly treated with statin drugs. So keeping in mind the common medical view is that high cholesterol is bad should also be considered when making health decisions.

The common (non-medicinal intervention) guidelines for treating high cholesterol include: eating a healthy diet, increasing exercise and stopping smoking. I would argue that the above studies don’t mean that everybody can eat poorly and not move, on the contrary I believe that the above studies show highlight how one factor of health shouldn’t be used to judge overall health and that healthy lifestyle choices are still the number one factor in improving health, not drug interventions.

I think they studies are coming from a health perspective that ‘high cholesterol’ shouldn’t be treated with drugs and that having ‘high levels of cholesterol’ shouldn’t worry people that are living an otherwise healthy lifestyle. Other more important factors include lack of exercise, smoking, body size & composition (including

Another study points to elevated triglyceride levels being a better factor to identify high risk individuals. Their statistical analysis concluded that LDL levels were statistically insignificant risk factor for coronary risk factors. “Increased triglyceride level, small LDL particle diameter, and decreased HDL-C levels appear to reflect underlying metabolic perturbations with adverse consequences for risk of MI; elevated triglyceride levels may help identify high-risk individuals.”

A 2009 study found that nearly half of patients admitted to hospitals because of heart attacks had normal or low LDL levels.

“Almost 75 percent of heart attack patients fell within recommended targets for LDL cholesterol, demonstrating that the current guidelines may not be low enough to cut heart attack risk in most who could benefit,” said Dr. Gregg C. Fonarow, Eliot Corday Professor ofCardiovascular Medicine and Science at theDavid Geffen School of Medicine at UCLA and the study’s principal investigator.

Are Triglycerides the real indicator? 

Triglycerides are a type of fat. They are the most common type of fat in your body. They come from foods, especially butter, oils, and other fats you eat. Triglycerides also come from extra calories. These are the calories that you eat, but your body does not need right away. Later, hormones release triglycerides for energy between meals. If you regularly eat more calories than you burn, particularly “easy” calories like carbohydrates and fats, you may have high triglycerides.

There is less controversy surrounding triglycerides and most of the evidence points to high triglyceride levels being directly linked to the diet, both what you eat and how much you eat.  Triglycerides differ from cholesterol because, triglycerides are fats and cholesterol is a waxy odorless substance that is an essential part of cell walls and nerves. Triglycerides are less reliant on internal bodily functions and more affected by external lifestyle factors.

Elevated triglyceride levels can increase blood viscosity and cause platelet aggregation, which both lead to slower blood flow, because the blood is now thicker and stickier.

Triglycerides may become elevated with obesity, physical inactivity, high-carbohydrate diet, cigarette smoking, alcohol, diseases such as diabetes and renal failure, drugs including estrogen and corticosteroids, and genetic disorders

Healthy triglyceride levels are shown in the chart below. There is also some controversy in the role that elevated triglyceride levels play in the causality of heart problems, because high levels are also found with a host of other problems, so pinpointing exactly what the cause is is hard to identify. However, just like with cholesterol, triglyceride levels should be seen as another health marker and their other test results and lifestyle choices should be taken into account when assessing what triglyceride levels mean.

Screen Shot 2018-06-19 at 6.46.11 AM

Medline Plus

There is also a problem associated with low triglyceride levels, which is considered a result of less than 35. This is slightly less of a problem and is caused by: hyperthyroidism, malnutrition, super low fat diet, certain drugs and malabsorption syndrome.

Both high and low levels or triglyceride levels are asymptomatic and are generally used as another layer of factors when considering a person’s health.

Calculating LDL using the Iranian formula

Standard blood tests don’t measure LDL directly, instead for a standard lipid profile, the amount of LDLs in the bloodstream is estimated using the Friedewald equation, more detail can be found here. I won’t go into the mathematics, however, when I plug in my own data into the online calculator, the Freidwald and Iranian values match up with my own lipid tests.

The Iranian formula is best used when a person displays low fasting triglyceride levels, as this low value throws off the standard Friedewald formula.

The calculator can be found here:
https://www.thecalculator.co/health/LDL-Calculator-683.html

Date Total
Cholesterol
HDL LDL Triglycerides Calculated LDL
Apr-15 222 53 152 86 146
Aug-16 208 56 139 64 120
Apr-18 234 57 169 41 128

According to the Iranian formula my estimated LDL value falls within the ‘healthy’ range.

How to lower triglycerides… and cholesterol

Just like with cholesterol, lifestyle factors are the best thing to change when trying to lower their levels. Besides medical and drug intervention, general recommendations across the board include:

  • Increase levels of exercise
  • Lose some weight
  • Reduce overall calorie consumption
  • Choose better fats
  • Reduce alcohol intake
  • Avoid sugary & highly processed foods
  • Increase consumption of high omega-3 foods

My conclusions

Based on all the research I’ve done, I think cholesterol and triglyceride levels are a simple pieces of a puzzle that fits into the larger picture of a person’s health. I don’t think high levels alone are indicative of a person’s potential risk of CVD. If taken as an isolated metric, there would be alarm bells ringing. If elevated levels of blood lipids are evident, in addition to other negative health markers and an individual isn’t displaying a typical ‘healthy lifestyle’ then that’s when we should worry. However, if there are no other signs of negative indicators of poor health, then there might be something further to investigate and/or nothing to worry about.

The best thing a person can do is adopt a healthy lifestyle regardless of their blood lipid panels and shouldn’t stop living a healthy lifestyle if/when their levels go back to normal. Nor should elevated levels be cause for alarm or medication.

References:

 

https://www.huffingtonpost.com/dr-mercola/the-cholesterol-myth-that_b_676817.html
https://www.everydayhealth.com/high-cholesterol/treatment/10-things-you-need-to-know-about-inherited-high-cholesterol/
https://www.health.harvard.edu/heart-health/making-sense-of-cholesterol-tests
https://www.health.harvard.edu/heart-health/11-foods-that-lower-cholesterol
https://www.thecalculator.co/health/LDL-Calculator-683.html
https://medlineplus.gov/cholesterol.html
https://en.wikipedia.org/wiki/Cholesterol
https://www.cambridge.org/core/journals/british-journal-of-nutrition/article/dietary-cholesterol-from-physiology-to-cardiovascular-risk/2AD4493E735677B9298CCC17FA790539
https://www.mayoclinic.org/diseases-conditions/high-blood-cholesterol/in-depth/triglycerides/art-20048186
https://articles.mercola.com/sites/articles/archive/2016/06/29/cholesterol-heart-disease-important-facts.aspx
https://www.telegraph.co.uk/science/2016/06/12/high-cholesterol-does-not-cause-heart-disease-new-research-finds/
http://annals.org/aim/fullarticle/729152/narrative-review-lack-evidence-recommended-low-density-lipoprotein-treatment-targets
https://www.ncbi.nlm.nih.gov/pubmed/8782637
https://www.medicinenet.com/triglyceride_test/article.htm#what_are_triglycerides
https://medlineplus.gov/triglycerides.html
https://www.mayoclinic.org/diseases-conditions/high-blood-cholesterol/in-depth/triglycerides/ART-20048186?p=1
https://www.sciencedirect.com/topics/biochemistry-genetics-and-molecular-biology/triglycerides
http://healthcorrelator.blogspot.com/2013/12/the-friedewald-and-iranian-equations.html
http://newsroom.ucla.edu/releases/majority-of-hospitalized-heart-75668

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