By Dr Joe
My cholesterol is high. Help!
Should I worry about my high cholesterol? With all the conflicting messages on you tube, blogs, twitter and facebook, it’s not surprising that people get confused about cholesterol levels.
You go to your doctor who requests lipid profile on your behalf or you order some blood tests online (you know you can do that now, don’t you?). Results come back. And voilla, your cholesterol level is high and you are not sure what to do.
You’re confused. Worse still, your doctor is not giving you straight advice because he too is confused about the significance of high cholesterol.
Why is your doctor confused?
It’s because there’s so much conflicting medical publications out there that it just gets even more confusing for us in the medical world.
Well, relax. Because on this page I am going to try and clear the confusion for you. At the end of this article, you should know what to do. Hopefully feel more reassured too.
I will give you an explanation as to why some folks have heart attacks despite normal cholesterol levels. The last word on cholesterol on the basic level…
So, should I worry about my high cholesterol?
Good question. Now it’s not a straight Yes or No answer. It’s a little more nuanced than that.
It’s high cholesterol level concern a myth?
First of all, where’s the high cholesterol concern coming from. It’s mainly from the potential damage that high cholesterol can cause on the walls of our arteries.
The ultimate damage being atherosclerosis and plaque formation on the arteries. That’s the concern. And with heart disease and stroke causing so much deaths and disability, it makes sense to know what to do with your cholesterol numbers.
But that is not always an easy thing to do. In fact, it is a challenge in itself.
The Challenge of the Cholesterol confusion
Everyone is an expert these days. Even more worrying is everyone is an expert on cholesterol these days. That’s fine.
What is not fine is; how everyone is chest-puffing about how much they know about cholesterol. The cholesterol fight has become inextricably tied to the polarity of the diet world.
In one corner, we have the meat-lovers. These folks are transfixed on hovering up as many animal products as possible.
On the other corner are the vegans. Naturally, these are plant-based eaters. It’s just that veganism is an extreme form of plant eating.
What is clear is that in the majority of meat lovers, there seem to be a problem with their bodies handling cholesterol in one form or another. Either they have problems with Total cholesterol, or problems with LDL Cholesterol (the bad cholesterol) or even their triglycerides or a combination of those parameters.
The vegans on the other hand seem to do fairly well, within reason, that is. Because not all vegans are healthy eaters.
There’s a perception out there that all vegans are healthy. Nope.
There are lots of unhealthy vegans about and some of them do have issues with cholesterol too.
Yes, both groups may end up with cholesterol issues but the meat lovers win hands down in the poor cholesterol performance stakes.
So, to defend their corner, the animal food loving Gurus tell their crowd not to worry about their cholesterol numbers. They reassure their followers that cholesterol does not cause heart disease or strokes. They should go to bed and sleep well. Nice!
The only group that seem to point out a cautious message to their followers are are the vegans. If your cholesterol numbers are abnormal, do something about it. Seems reasonable to me…
Obviously those in the middle between veganism and carnivorism would want to pay attention to that warning too.
But is it right to tell people not to worry about your cholesterol numbers?
Would that be an ethical thing to do?
Some Cholesterol background information
Okay let’s delve into some background information regarding cholesterol because it will help us understand where we stand better.
The concern is; atherosclerosis, right? Yes, it is.
The truth is; there are many factors involved in the development of atherosclerosis. One of them is cholesterol. That should not be in question.
What is in question is whether cholesterol is there in the beginning, the orginator, an active participant or just there as a byestander.
What’s cholesterol’s contribution to the development of atherosclerosis?
Few facts:
1. Not everyone with high cholesterol will develop atherosclerosis and consequent build up of plaque. Meaning not everyone with high cholesterol will suffer a heart attack and or a stroke.
2. On the flipside, people with life long very low cholesterol levels hardly develop plaques in their arteries leading to heart attack and strokes.
Those 2 facts do leave you with a conundrum, right?
Some Basic Cholesterol Biochemistry
Okay, let’s do some basic biochemistry as it relates to cholesterol.
Fats are insoluble in water. I’m sure you know that from your kitchen dealings already.
Unfortunately, blood is 90% water. But we need to move our cholesterol from one part of the body to another.
To do that knowing that cholesterol is fat and it wouldn’t dissolve in water i.e blood, then, we are going to need a transport system. We need a solution…fast.
Cue, Proteins. Hurray!
Yes, proteins are going help us move our cholesterol fats in blood from one place to another. Around the body, that is. Proteins are going to be the “taxi” that will ferry our cholesterol from one tissue to another. I like that.
These proteins are called carrier proteins. These proteins will be moving fats like Cholesterol, Triglycerides and Phospholipids around the body for us. Perfect.
So, the combination of Fat plus its carrier protein is called Lipoprotein.
And Lipoproteins are what’s going to interest us when it comes to cholesterol and it’s potential problems.
Why do the Lipoproteins interest us?
Here’s the reason why lipoproteins are significant to us. It’s because lipoproteins may have their greasy hands in the causation of these killer diseases.
Lipoproteins (remember they are a combination of fat and proteins) are the molecules that interact with the walls of our arteries to trigger a cascade of events that cause inflammation.
Finally, that word. Inflammation. I know you have been waiting to hear it. Or should I say, read it.
Yes, inflammation is what leads to atherosclerosis and subsequent plaque build up.
And lipoproteins carrying cholesterol are involved in that inflammatory process. Cholesterol is not alone in that inflammatory process. there other agents too – white blood cells, macrophages, inflammatory mediators, platelets, T-cells etc.
Where opinion is divided is whether the presence of the cholesterol kicks the whole inflammatory process off or cholesterol comes in later on in the process.
That debate will go on for a while. Some of us believe that small particle dense cholesterol is the trigger for the inflammation.
Some other people believe in theory that, there some microtears or physical injury that occur on the arterial wall and cholesterol latches on to the tears and it all kicks off after that.
Yet, there are also the animal lovers who believe that just because cholesterol is there doesn’t mean it was involved. These folks believe cholesterol is just a byestander in that ‘scene of crime’. Interesting concept, huh?
It is these individuals that will tell you not to worry about your cholesterol numbers. Because cholesterol is an innocent byestander. Of course they hold on to the argument that not veryone with high cholesterol ends up having a heart attack or stroke.
That’s true but they are mistaken and I shall give you an explanation as to why shortly.
Back To Cholesterol Biochemistry
Okay, I went off on a tangent there. But an important one, you have to admit.
So, where was I? Oh, yes, I was talking about Lipoproteins.
You know 2 of them already because we never stop talking about them. There are actually 5 different types of lipoproteins. And they are:
- High Density Lipoprotein (HDL cholesterol) – The Good cholesterol
- Low Density Lipoprotein (LDL cholesterol) – The Bad cholesterol
- Intermediate Density Lipoprotein
- Chylomicrons
- Very Low Density Lipoprotein (VLDL cholesterol) – carries Triglycerides
The 2 most popular ones are the bad cholesterol (LDL cholesterol) and the good cholesterol (HDL cholesterol). Popular because everyone keeps talking about them. That’s a good thing because the awareness is there.
Of the other 3 lipoproteins that aren’t so popular, the most important one is the VLDL cholesterol. You can ignore the chylomicrons and intermediate density lipoproteins because they aren’t so important clinically.
But VLDL cholesterol is one you need to be familiar with because this is the lipoprotein that carries triglyceride fats. And this is very important.
As for the HDL cholesterol, the so-called Good Cholesterol, it is named that for a reason. The HDL cholesterol is a scavenger cholesterol. It carts away cholesterol from the walls of our arteries. Takes it to the liver for processing and possible excretion.
So, what cholesterol should you worry about?
Now that we are done with our basic knowledge of cholesterol and their carrier proteins. Let’s turn our attention to the cholesterol that should concern you and your health.
Should you worry about your cholesterol numbers?
Here’s the truth.
Your total cholesterol (the sum total of your cholesterol parameters) only gives you an overview of your cholesterol status. It is okay to look at this cholesterol figure but note this:
Your total cholesterol is a poor predictor of your risk of having a heart attack or stroke. High or Low Total cholesterol doesn’t mean a lot in terms of predicting if you are at risk of a heart attack or stroke.
Interesting, right?
So, if your total cholesterol doesn’t tell you a lot, what does?
How about we talk about the bad cholesterol i.e LDL cholesterol. They don’t call it “bad” for nothing.
This one is important but even then LDL cholesterol is only important up to a point.
What do I mean by that? I’ll tell you now.
Does Cholesterol size matter?
Oh yes, the old well worn out debate. Does size really matter? Actually it does when it comes to LDL cholesterol.
Cholesterol particle size matters…a lot.
Here is the thing:
LDL cholesterol comes in 2 different sizes – Large particle LDL cholesterol and Small particle LDL cholesterol.
The large particle LDL cholesterol is fluffy and cotton wool-like whilst the small particle LDL cholesterol is dense.
Studies have shown that the small dense particle LDL cholesterol is one cholesterol to worry about. Because people whose cholesterol is predominantly small particle dense cholesterol are 3 times more likely to have Coronary Heart Disease.
And guess what. There’s a suggestion that the large particle LDL cholesterol could be protective of Coronary Heart Disease. Are you following?
So, LDL cholesterol can be harmful or beneficial at the same time. But which way it swings depends largely on whether you have a predominance of small particle LDL or large particle LDL.
The predictive value of LDL cholesterol giving a heart attack or stroke is poor unless you break it down to small or large particle. Makes sense?
Can I have a heart attack with normal Cholesterol numbers?
Answer to that question: Yes, you can.
Let me explain:
The reason some people with normal Total cholesterol and normal LDL cholesterol numbers end up having a heart attack is because of the their small particle dense cholesterol concentration.
Oh yes. You can have a normal range of bad cholesterol but if within that normal range, you have a relatively high small dense LDL cholesterol, your risk of a heart attack goes through the roof.
If your risk is high (and you do nothing about it), then it is a question of ‘when’ not ‘if’.
Does that explain why that happens and tends to make people feel bewildered when it happens.
It’s all about how much small dense LDL cholesterol you have. That matters a huge deal.
How about that Pesky VLDL cholesterol?
Should you worry about your VLDL cholesterol?
I’m glad you asked.
Yes, that VLDL cholesterol (remember it carries the Triglycerides) is another cholesterol that should concern us. Why?
The reason is this:
High Triglycerides levels in your blood correlates with a high Small particle dense LDL cholesterol. In the same vein, low levels of Triglycerides floating around correlates with high levels of large fluffy LDL cholesterol.
Meaning your blood Triglyceride level can be a window to knowing your small particle LDL or large particle LDL cholesterol status. Especially in individuals who cannot access Lipoprotein Sub-fraction testing which I shall be talking about shortly.
So, what should you do if you are worried about your cholesterol numbers?
Here’s what you need to do if your cholesterol numbers on the standard lipid panel come back as abnormal.
Do not worry too much about your Total cholesterol number. Poor predictor, remember?
Look at the LDL cholesterol and the Triglycerides. If they are abnormal, request lipoproetin sub-fraction testing from your doctor. It’s called LDL-P testing. Whilst you are at it, also ask for Apolipoprotein B.
LDL-P and Apolipoprotein B are better predictors of your risk of coronary heart disease or stroke. They are way better markers than your LDL cholesterol alone.
Remember LDL cholesterol number is just the total concentration of cholesterol in the LDL. It does not tell you the differential particle concentration within the LDL molecule. That’s why sub-fraction testing which breaks down the particle concentration is the way to go.
Of course, if you want to take things to the next level, then Calcium scanning of your coronary arteries will be a reasonable step too.
Having said that, I also know that there are readers of this article who may not have access to those specialised tests either for reason of cost or test availability in their locality.
If you are one of those people, then you should take your VLDL cholesterol result on the standard lipid panel seriously because of it’s correlation with small particle LDL.
Also in the absence of specialised subfraction testing, you should assume your risk of heart disease to be high if your LDL cholesterol is high especially if your Triglyceride is high too.
Can I have the LDL-P Reference range?
To round up, I feel I should let you have a reference range for LDL-P testing if you can access the test through your doctor.
Remember, we are using this test to assess our risk of heart disease and or stroke. So it makes sense to know what the result you get back means.
Here’s how to interprete your LDL-P result:
<1000 – Your Risk is Low
1000-1299 – Your Risk is Moderate
1300-1599 – Your Risk is Borderline High
>1600 – Your Risk is High, Buddy.
Now how was that. I told you this was going to be your last word on your cholesterol concerns. Did I deliver on that promise? Let me know below please…if you can.
Have you checked out how insulin resistance contributes to high blood pressure…
Dr. Joe