Cholesterol: The Good, The Bad, and The Balance (and why statin therapy might be necessary)

 

“I’ve been told I have high cholesterol!”.  “Which is the good cholesterol, and which is the bad one?”  “What do these numbers on my blood test mean?”  “Why has my Doctor prescribed statins?”  “My doctor’s told me to “eat healthy” but what should I eat?”…….. 

In the years before I graduated from Mac Nutrition University as a Certified Nutritionist, I had a basic understanding of cholesterol at best. I was unaware of the things I now feel I should have known in order to be better informed about my health.  It is such an important topic that MNU devoted an entire lecture to it.

I hope to address some of these pressing questions that come up in the field of nutrition coaching practice. I’ll try not to get too carried away with the science!

Before I start, I want to stress that this blog is intended to help inform and educate and is NOT a replacement for specialist medical advice, neither is it intended to replace any advice for anyone currently under the direction of a Registered Dietition.  You should always refer to your Doctor, or RD, if you have any specific medical conditions or concerns.

Simplifying The Complexity of Cholesterol

Cholesterol plays a vital role in various physiological processes. It supports cell membrane structure, hormone synthesis, and bile acid production. The human body tightly regulates cholesterol levels through a complex system involving endogenous (inside the body) cholesterol production, and dietary intake (exogenous).

Endogenous cholesterol production occurs primarily in the liver and serves as the building blocks for various essential functions within the body.  Excess endogenous cholesterol can contribute to the formation of plaque in the arteries, leading to atherosclerosis (artery clogging) and increased cardiovascular risk. (See also “Myths” below).

Dietary cholesterol, on the other hand, refers to cholesterol found in the foods we eat such as eggs, meat, and dairy products.  We now know that dietary cholesterol has little impact on cholesterol levels, except in the case of ‘hyper-responders’, ie, those for whom dietary cholesterol does raise levels of both LDL and HDL cholesterol.

Despite its association with cardiovascular risk, cholesterol is not inherently harmful for most people. It is the intricate interplay between cholesterol levels, inflammation, and other risk factors that ultimately determines an individual’s cardiovascular risk profile.

For the most part, we can control the balance between the ‘good’, and the ‘bad’ cholesterol in our blood, by adopting a healthy lifestyle and dietary management approach to our well-being. For some individuals, however, non-modifiable determinants such as genetics (family history), diabetes (especially Type1), age, ethnicity, etc, mean that even despite health-seeking disciplines, the need for prescription statins for controlling cholesterol cannot be avoided.

Cholesterol Types - “Which is the good one, and which is the bad one?”

• LDL (Low-Density Lipoprotein). This is often referred to as the “bad” one. To remember it, think of it as “L for Loathesome!”.  LDL carries cholesterol from the liver to cells in the body.  High levels of LDL are associated with an increased risk of cardiovascular disease. There are many sub-types of LDL.  VLDL is worthy of note (let’s call it “Visciously-Loathesome”), because it contains the highest concentration of triglycerides. Chronically elevated triglycerides is something your doctor doesn’t want to see on your blood test.  Let’s be clear though, we don’t want to get rid of LDL cholesterol altogether, we NEED it to survive.  What the body strives to achieve (with our help through a health-seeking lifestyle) is a balance between HDL and LDL.
• Triglycerides: Often overshadowed by our attention on LDL cholesterol, triglycerides play a critical role in cardiovascular health. Elevated triglyceride levels, known as hypertriglyceridemia, can increase the risk of heart disease and stroke. For this reason, the breakdown of your blood test results will single out triglyceride levels for control measures.  There are also strong links between triglycerides and insulin resistance (cause of Type 2 Diabetes). A key measure of controlling triglycerides in the blood, is controlling the QUALITY of carbohydrates in our diet, as well as significant reduction of trans-fats found in ultra-processed foods (more on this below).
• HDL (High-Density Lipoprotein): Known as the “good cholesterol”. Remember this one as the “H for Happy”.  Interestingly, HDL is not actually cholesterol, it’s a lipoprotein (a fatty protein).  This is why, on your blood test, you might see “HDL” and “Non-HDL” readings; the latter being everything else, after the ‘”good cholesterol, or HDL” is removed. HDL helps remove excess cholesterol from the bloodstream and transport it to the liver for excretion. High levels of HDL are associated with a lower risk of heart disease.
• Balancing HDL with LDL: While specific ratios may vary, a higher HDL level relative to LDL is generally considered beneficial to heart health.  Which brings me neatly on to:…

Deciphering Cholesterol Readings: “What do these numbers on my blood test mean?” 

Depending on what country you live in, cholesterol levels are measured either in milligrams per decilitre (mg/dL), or millimoles per litre (mmol/L).

For Spain (where I live), a Total Cholesterol level no greater than 200mg/dL is preferred, while in the UK, it’s a Total Cholesterol level of no greater than 5mmol/L is preferred.  These measurements are considered to be the threshold for increased cardiovascular risk.

Let’s broaden this in the example below:

Cholesterol Level	Desirable Range (mg/dL)
Total Cholesterol	No greater than 200
LDL (LDL-C)	No greater than 100
HDL (HDL-C)	Above 40 (men). Above 50 (Women)
Triglycerides	Less than 150

So, how do we convert mg/dL to the United Kingdom standard equivalent, mmol/L?  Look at the example below:

• To convert 200mg/dL to mmol/L, we apply this conversion factor: 1mg/dL = 0.02586mmol/L
• 200mg/dL multiplied by 0.02586mmol/L = 5.17mmol/L

Therefore, 200mg/dL is approximately equivalent to 5.17mmol/L in the UK standard.

The LDL cholesterol target level may vary depending on individual risk factors. Several factors can influence an individual’s risk of developing cardiovascular disease (see the section about statins below).

For example, a person with established cardiovascular disease or multiple risk factors such as diabetes, high blood pressure (hypertension), smoking, or obesity, may have a higher baseline risk of experiencing a cardiac event compared to someone with no known risk factors. In such cases, a more aggressive LDL cholesterol target may be warranted in order to reduce the risk of future events.

Conversely, people with few risk factors or no history of cardiovascular disease may have a lower baseline risk and may not require as stringent LDL cholesterol targets. In these cases, a more tailored approach to achieve moderate reductions could be taken while minimising the potential for adverse effects from intensive therapy.

Debunking Common Myths

Myth: Saturated fat is inherently bad for your heart.

Reality: The link between saturated fat and heart disease has been extensively studied. It’s long been recognised that not all saturated fats are created equal and their effects on cholesterol levels differ, depending on various factors. (See my blog archive for "High Fat Foods", where I talk more about saturated fats)

For example, coconut oil is high in saturated fat and has been shown to raise both HDL and LDL cholesterol levels, yet, it may also have beneficial effects on other risk factors for heart disease, such as inflammation and insulin sensitivity (ability to control insulin).

The American Journal of Clinical Nutrition found no significant evidence to suggest there was an association between saturated fat and heart disease.  Rather, the authors of the study concluded that the type of foods consumed in place of saturated fats may have a greater impact on cardiovascular health. One of the greatest ‘players’ here is trans-fats (man-made, industrialised fats, found in ultra-processed foods).

Myth: Dietary cholesterol from foods like eggs raises cholesterol levels in the blood.

Reality: Contrary to once-held beliefs, dietary cholesterol from foods like eggs does not necessarily lead to high cholesterol levels in the blood. In fact, eggs are considered a nutrient-dense food that can be part of a healthy diet. They are rich in high-quality protein, vitamins, minerals, and antioxidants, making them a valuable addition to a balanced diet.

It is worth remembering, however, that individual responses to dietary cholesterol may vary, particularly in those with specific genetic conditions like familial hypercholesterolemia (predisposition to high cholesterol through family history).

Exploring Why Statin Therapy Might Be Unavoidable

So, your blood test reveals that your total cholesterol is high and your doctor has prescribed statin therapy.  You might understand why they have done this, especially where your knowledge of family history precedes the diagnosis.

Hopefully, your doctor will have questioned your lifestyle and dietary habits. Matters such as: exercise and how much, sleep quality, diet, alcohol consumption, smoking, and stress should all be causes for investigation. If you are already seeing your doctor for obesity, diabetes, high blood pressure, etc, then these will also be major factors for consideration.  These considerations, and others, will enable your doctor to determine if statin therapy should be prescribed.

If all diet and lifestyle markers are otherwise good, then your doctor will diagnose that your body is simply not controlling cholesterol for itself, and that’s down to your genetics.  This is when statins are unavoidable.

Indications for statin therapy include:

Elevated LDL Cholesterol: Individuals with persistently elevated LDL cholesterol levels, particularly those with a history of cardiovascular disease or multiple risk factors, may benefit from statin therapy to lower their cholesterol levels and reduce their risk of future cardiac events.

Diabetes: People with Diabetes are at increased risk of developing cardiovascular disease and statin therapy has been shown to be beneficial in this population, even in the absence of elevated cholesterol levels.

History of Cardiovascular Events: Individuals who have experienced a heart attack, stroke, or other cardiovascular events are often prescribed statin therapy to prevent future occurrences and improve long-term prognosis.

High Cardiovascular Risk: Certain individuals, such as those with familial hypercholesterolemia or other genetic lipid disorders, may have a significantly elevated risk of cardiovascular disease and may require statin therapy, sometimes in combination with other lipid-lowering medications.

Statin medications work by inhibiting the enzyme HMG-CoA reductase (an enzyme that helps make cholesterol in your body), thereby reducing the liver’s production of cholesterol.

While statins are generally safe and well-tolerated, they can cause side effects in some individuals. Common side effects include muscle pain, weakness, and fatigue (occasionally through poor sleep). In rare cases, statin use may lead to more severe side effects such as liver damage or an increase in blood sugar levels. Additionally, some individuals may be unable to take statins due to contraindications or intolerable side effects. These may include individuals with severe liver disease, those who are pregnant or breastfeeding, or those taking certain medications that interact with statins. In such cases, healthcare practitioners will monitor their patients carefully to assess their treatment, so you should not be worried.

Statin therapy research is ongoing but, for now, they remain necessary. 

Regardless, What Lifestyle And Dietary Advice Should We Follow?

Excess body weight, particularly visceral fat (fat around the abdominal organs) is associated with unfavourable lipid profiles, including elevated LDL cholesterol and triglyceride levels, and reduced HDL cholesterol levels.

Sensible weight management that focuses on reducing calorie intake, calorie (energy) balance, increasing physical activity, smoking cessation, controlling stress, getting adequate sleep, and moderating alcohol can lead to improvements in cholesterol levels. Even modest improvements of 5-10% weight loss can lead to significant lipid profile improvements. 

Even if you cannot manage to lower your cholesterol levels through these protocols they are nonetheless ideal health-seeking practices that should be observed, since they represent a reduced risk for all-cause mortality health ailments. 

A diet that is rich in fruits, vegetables, whole grains, healthy fats, and lean proteins can lead to significant improvements in blood lipid profiles, as well as, of course, positive weight management outcomes.  Let’s look at some of the more important dietary protocols below:

High-Fibre Foods: consume plenty of high-fibre foods like fruits, vegetables, whole grains, legumes, and nuts. Fibre helps reduce cholesterol absorption in the gut and promotes heart health. Aim for 30-35g of digestible fibre a day.

Whole-Grains: Whole grains such as oats, barley, quinoa, brown rice, and whole wheat products are rich in soluble fibre, which can lower LDL cholesterol levels. Swap refined carbohydrates (white rice, white bread, etc) and sugars for whole grains wherever possible.

Healthy Fats: These are your monounsaturated fats (olive oil, avocados, and nuts), called MUFAs and polyunsaturated fats (salmon, flaxseeds, and chia seeds), called PUFAs.  Tipping the balance in favour of both MUFAs and (particularly) PUFAs against saturated fats (SFAs) will help lower triglyceride and LDL levels, while increasing HDL.

Limit Trans Fatty Foods: Reduce intake of processed meats (such as bacon, packet cold meats) and ultra-processed fatty foods such as potato chips (crisps), biscuits and cakes).  Consumption of a diet high in trans-fats has been associated with a 34% increase in all cause mortality, a 28% increase of coronary heart disease mortality, and a 21% increase in the risk of coronary heart disease.

Regular Monitoring: Regular check-ups and monitoring cholesterol levels are important, especially as we age.  Tracking progress will help adjust any dietary interventions accordingly.

Important Note: Sufferers of gut-related health conditions such as IBS, IBD, Crohns, Celiac Disease, etc, are advised to follow the advice laid out by either their healthcare practitioner or a Registered Dietitian, before making dietary changes.

Summary

Cholesterol management is a multifaceted endeavour that requires a comprehensive approach that includes paying attention to lifestyle modifications, dietary changes, and, in some cases, the prescribed intervention of statins and other therapies.

LDL cholesterol is not inherently bad. It’s a matter of helping the body strike a balance between HDL and LDL levels overall.  This is why making all the positive diet and lifestyle choices discussed above, are important. 

While statin therapy can be a valuable tool in reducing cardiovascular disease risk, healthcare practitioners (especially the forward-thinking, evidence-based ones) will weigh the benefits and risks carefully and individualise treatment based on each patient’s unique circumstances.

I hope this has provided you with a better understanding of cholesterol, cholesterol readings, and statin therapy.  I have tried to be as thorough as possible while focusing on the most important issues.

If you wish to seek expert guidance and personalised support to transform your health and well-being, why not consider becoming my client? I offer individualised nutrition counselling (including advice on supplements where applicable), deeply rooted in evidence-based practice, to help you achieve your goals.  Contact me via: beverleyforbesnutrition@outlook.com, or via Private Message on my Social Media Pages: @beverleyforbesnutrition.

Further reading: Citations referred to in the writing of this article are available on request