The Cholesterol Controversy: Why It’s Time to Unlearn Everything we Once Knew about Cholesterol

There once was a time when the medical world believed that bad air, or miasma, was the cause of infectious diseases such as cholera and the bubonic plague – also known as Miasma theory. This belief caused doctors to wear birdlike masks filled with flours and herbs to "purify" the bad air leading to the infamously terrifying images of medieval plague doctors.

In hindsight, it seems quite silly that medical professionals could have been so off base with their conclusions. But I often ask myself that if they were so sure about their theories back then despite being so wrong, what is to say that our own modern medical conventions are not equally off base?

True, we now practice “science-based medicine” but science itself is subject to a litany of errors, biases, profit motives, and the like…

In other cases, it turns out that we are just plain wrong despite all the evidence suggesting that we are not. Newton’s conclusions about gravity were once believed to be scientifically true and thus went unchallenged for over 200 years until Einstein came along and showed us that Newton’s findings were incorrect, albeit still useful.

This brings me to the science of cholesterol. For as long as I can remember, I believed that cholesterol is bad. I believed that we should avoid high cholesterol foods, and that having high blood cholesterol was a surefire way to die of a heart attack.

However, as I have challenged my own blind acceptance of status quo thinking, I have completely upended my understanding of cholesterol, and no longer subscribe to the conventional wisdom that continues to be perpetuated by most doctors and society alike.

What is cholesterol?

Cholesterol is a vital component for proper bodily functioning at the cellular level. It’s responsible for maintaining healthy cells, regulating hormones, vitamin D production and more. Without cholesterol, life cannot exist. It is so important that the body will produce it on its own to ensure that it always has enough, with the liver and intestines producing roughly 80% of all of the cholesterol present in the body.

Cholesterol is moved to cells in the body through the bloodstream via transport vehicles known as lipoproteins. Two of the most notable of these lipoproteins are HDLs, which unfortunately have earned the title of “good cholesterol,” and LDLs which tragically are referred to as “bad cholesterol.” One should note that lipoproteins are not cholesterol at all, but are in fact cholesterol transporters. Nonetheless, these lipoproteins are neither good nor bad in and of themselves.

From a logical standpoint I think it is totally valid to ask, “if cholesterol is so important, why would something so fundamentally necessary for our very existence also be deemed to be ‘bad’ for us in any appreciable quantities?”

Why is it villainized?

I’ll spare you the confusing jargon that only doctors can understand, which loses every one else. But the basis of our negative views on cholesterol comes from the lipid theory which used epidemiological studies to identify a correlation between cholesterol and cardiovascular disease. This theory observes that LDL cholesterol is strongly correlated with cardiovascular diseases. However this theory is not without its many critics. A plethora of research has been published which outright disputes the positions of the lipid theory.

To my knowledge the lipid hypothesis shows a clear causal relationship between LDL and cardiovascular disease.

We can also identify a clear correlation between car accidents and ambulances. Wherever there is a car accident, there likely is the presence of an ambulance as well. But would it be right to conclude that the ambulance has caused the accident?

This is essentially what the lipid theory does with LDL cholesterol.

For example, with an estimated 88% of Americans being metabolically unhealthy, could it be possible that epidemiological studies are subject to sampling errors in which the average participant’s metabolism is operating in an abnormal state thus leading us to draw false conclusions about the nature of the human body?

To what degree have various cholesterol studies differentiated between metabolically healthy and metabolically unhealthy participants when the standard diet has put the majority of the population into a state of low-grade chronic inflammation? And most importantly, if we have found the ”cause” of cardiovascular disease, and we have spent decades eradicating the source, then why does it continue to be one of the leading cause of death in the modern age?

The skinny

Doctors take blood cholesterol samples most commonly using tests that measure total HDL and LDL cholesterol. When it comes to LDL there are different subtypes known as small dense LDL and large buoyant LDL. The tests that doctors typically run do not differentiate between these two subtypes.

The larger buoyant particles are large enough and light enough to harmlessly float in the bloodstream while the small dense particles on the other hand are more likely to sink with the potential of latching onto damaged sections of the arterial wall.

Small dense LDL particles are shown to be one of the main indicators of increased cardiovascular risk.

A person who has a high LDL reading which consists of mostly larger buoyant particles is likely at much less risk than a person with a low LDL reading consisting of mostly damaging small dense particles. Yet, conventional medical practices will see the person with the higher LDL likely misdiagnosed, and put onto a statin drug that could result in health complications for an otherwise healthy person.

In other words, despite the industry standards, LDL cholesterol in and of itself is possibly not a reliable indicator of cardiovascular health.

One must take a closer look at LDL subtypes to understand, as there exists strong evidence that the size and quality of LDL particles may be a stronger predictor of undesirable cardiovascular issues.

How are small dense LDLs harmful?

Small dense LDL counts tend to be higher in people who are less metabolically healthy.

Some of the main drivers of lowered metabolic health include insulin resistance, inflammation, oxidative stress, refined sugars and carbs, trans fats, and sedentary lifestyles.

In addition to higher small dense LDL ratios, in various ways these metabolic factors cause damage to arterial walls which creates opportunities for the small dense LDL particles to sink and latch onto the damaged sections of the artery.

Once this happens oxidation occurs triggering an inflammatory response inside of the artery that ultimately results in a foamy substance being delivered to the area to repair the damage. This is essentially how plaque builds up, leading to cardiovascular health problems down the line.

In other words, it seems that the presence of small dense LDL in combination with the damaging effects of metabolic dysfunction may be the real driver of cardiovascular disease. Remember the stat at the beginning of this article, 88% of the US population suffers from some degree of metabolic dysfunction. This means that for 9 out of every 10 people in the US, high LDL readings may actually imply a higher level of small dense LDLs compared to having more prevalent large buoyant LDLs which are less harmful.

For me, this suggests that cardiovascular risk should be addressed by improving metabolic functioning rather than insisting on lowering arbitrary lipid panel scores that do not distinguish between the size or quantity of LDL subtypes.

The following steps can be taken to reduce metabolic dysfunction and minimize small dense LDL prevalence in the body.

• Eating a diet that contains healthy fats from whole and minimally processed foods

• Eating a diet that is low or moderate in carbohydrates

• Increasing omega-3 intake preferably from whole food sources like salmon

• Reducing chronic stress

• Getting plenty of sleep

Dietary Cholesterol

Growing up, I like everyone else held the belief that high cholesterol foods were very bad.

After I began my fitness journey, I started to become a bit skeptical about the cholesterol myth because it seemed to me that the most nutrient dense foods that promote lean muscle growth also seemed to be foods which were high in cholesterol.

I specifically remember going to the doctor for routine labs one time, and when my LDL cholesterol registered above the recommended limit, the nurse practitioner casually instructed me to cut back on red meat and even teased the idea of putting me on a statin drug.

The nurse practitioner’s guidance came despite the fact that in 2015 the American Heart Association released new guidance on cholesterol that specifically stated..

"available evidence shows no appreciable relationship between consumption of dietary cholesterol and serum cholesterol… dietary cholesterol is not a nutrient of concern for overconsumption.”

Translation – everything you were told about avoiding high cholesterol foods was misguided.

Unfortunately, after decades of screaming from the hilltops to not eat cholesterol, the guidelines have been quietly reversed with little fanfare. Apparently many medical professionals did not get the memo because far too many still have their patients removing the extraordinarily nutritious egg yolks out of their eggs and cutting back on red meat in the name of not eating too much cholesterol.

Blood cholesterol

If dietary cholesterol does not increase serum (blood) cholesterol, then what does?

Cholesterol is produced mainly in the liver at exactly the quantities that is required. The metabolic conditions in the body will largely determine how much cholesterol the body needs.

But if the body determines how much cholesterol it needs, then how is it also producing an overabundance of “bad” LDL cholesterol? Could it be that the body is just doing it’s job and that the amount of cholesterol in the body is virtually irrelevant? Many doctors seem to think so.

As discussed before, it may be the case that the ratio of LDL subtypes matters more than the total LDL count. A simple google search will produce a trove of articles fixated on LDL count rather than small vs large particle ratios. What’s more, the said articles will typically promote a high carb, low fat, diet as the means for lowering LDL. Ironically, these are the very diets that spike insulin, spur weight gain, and promote metabolic dysfunction.

When we stop focusing on LDL count and instead focus on LDL particle size, we are driven towards higher fat and lower carb diets that promote more stable insulin levels, lean body mass, and metabolic health. The LDL reading may be high, but these particles will consist mostly of large buoyant particles.

What’s more, because one of the roles of LDLs is to carry fat through the bloodstream, when the body is in fat burning mode LDLs can actually go up. That’s right, if you begin making healthy diet and lifestyle choices, you may see a rise in your cholesterol.

The misdiagnosis epidemic

When it comes to treating basically any sort of ailment, or even non-issues, my experience has been doctors quickly turning to prescription medication. This also seems to be the case for cholesterol and the widespread use of statins.

When focusing on lowering cholesterol, statins work wonders. But as discussed before, if lowering cholesterol is the wrong goal to aim for in the first place, then is it possible that statins could be doing more harm than good?

Over the past few decades, the upper limit for acceptable levels of LDL at which a patient may begin treatment with statin drugs has dropped precipitously to the point where it’s becoming nearly impossible for even the most metabolically healthy individuals to fall within the range.

Current guidelines imply that up to 40% of Americans should be on cholesterol-reducing statins despite studies that suggest this number should be far lower, closer to 15%.

Side effects of statins include fatigue, dizziness, and sleep problems, all of which inhibit a person’s ability to live a lifestyle that actually promotes metabolic health; resistance training, excellent sleep, reduced inflammation from stress, etc..

I truly do not understand the inner workings of the drug industry or statin market, but as the saying goes, when you have a hammer, every problem begins to look like a nail. Could it be that with so much money, intellectual property, and profits tied up into the statin industry, every cardiovascular health problem begins to look like a LDL cholesterol issue which is conveniently treatable with statins?

The United States in particular is notorious for it’s overuse of statins compared with it’s European counterparts. The statin market in the United States projected to grow to $4.9 Billion by 2029.

Where will that growth come from? There are companies depending on people to become “sick” enough to require their drugs, and one of those people may very likely be you, whether you need them or not.

How to know if cholesterol is a problem?

I have found Dr. Robert Lustig’s formula for quickly deciphering standard lipid panel results to be useful. The interpretation which he lays out in his book, “Metabolical: The Lure and Lies of Processed Food, Nutrition, and Modern Medicine,” are as follows:

• If HDL is 60 or higher, then you are metabolically healthy and at low risk for cardiovascular disease. And HDL level below 40 for men and 50 for women indicates greater cardiovascular risk

• If LDL levels are below 100 then there is generally no cause for concern. If LDL levels are between 100 and 300, then the next thing to look for is triglycerides below 150. If they are above the 150 mark then it is a sign of poor metabolic health.

• If the HDL/triglyceride ratio is greater than 2.5 (Caucasians) or 1.5 (Afro Americans) then this is a sign of poor metabolic health.

I now use this information to interpret my own bloodwork so that I can not only discuss my results with my doctor, but also ask pointed questions especially if they bring up the idea of statins or become fixated on LDLs without considering everything else such as my diet and lifestyle.

Final words

I have realized that just as in any other industry, many professionals in the medical space are not exactly going above and beyond to put scientific dogmas aside, challenge conventional wisdom, and employ critical thinking beyond regurgitating what was learned in school or issued as guidance. Apathy and passive acceptance of information is the name of the game.

Sometimes I want to be upset with doctors who casually read off some standard guideline without taking the time to offer truly personalized care by understanding the whole of the patient. Afterall, patients are the ones who must live with the boilerplate solutions that doctors offer.

It’s also important to note that I am not a medical professional. I’m just a guy who is infatuated with the inner workings of the human body and explores the many rabbit holes that are out there to satisfy my curiosities. So whatever you do, don’t take my word for it. Do not trust me at all. Instead, do your own research and explore some of the concepts that I discussed to draw your own conclusions in consultation with your doctor.

Since the cholesterol topic is both highly debated and convoluted. I’ve also provided a number of readings that I found quite useful in better understanding diet, cholesterol, and metabolic health:

• The Great Cholesterol Myth: Why Lowering Your Cholesterol Won't Prevent Heart Disease, and the Statin-Free Plan that Will (Dr. Stephen Sinatra, MD, CNS and Dr. Jonny Bowden, PhD, CNS)

• Metabolical: The Lure and Lies of Processed Food, Nutrition, and Modern Medicine (Dr. Robert H. Lustig, MD, MSL)

• The Big Fat Surprise: Why Butter, Meat, and Cheese Belong in a Healthy Diet (Nina Teicholz, Investigative Journalist)

• Why We Get Sick: The Hidden Epidemic at the Root of Most Chronic Disease - and How to Fight It (Dr. Benjamin Bikman, PhD)

• The Obesity Fix: How to Beat Food Cravings, Lose Weight, and Gain Energy (Dr. James Di Nicolantonio, PharmD and Siim Land, anthropologist)

• Lies my Doctor told Me: Medical Myths that can Harm Your Health (Dr. Ken Berry, MD)