DO I REALLY NEED

TO WORRY ABOUT
MY CHOLESTEROL?

DR. BRET SCHER

DO I REALLY NEED TO WORRY
ABOUT MY CHOLESTEROL?
I get this question every day. Multiple times per day. So, you would think that I had a
simple one word answer to it. But alas, it is not so simple. The answer, of course, is a
big whopping MAYBE!

I know, I know. That is completely unhelpful. But let me explain. Hopefully by the
time you finish this brief (or not very brief depending on your attention span)
explanation, you will know if YOU as an individual should worry about YOUR
cholesterol. Not your neighbor. Not your friend. Not your favorite celebrity. But YOU.

The common teaching is that we all need to worry about high cholesterol and we
all should try to lower it as much as possible. But that is just plain wrong.

Don’t get me wrong. LDL cholesterol is not unimportant and should not completely

DO I REALLY NEED TO WORRY ABOUT MY CHOLESTEROL?

be ignored. Instead, it means we need to put cholesterol in context.

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DEFINITIONS
First the definitions (skip this part if you already have a basic understanding of
cholesterol subtypes)

Lipoproteins- These are transport vehicles for LDL, HDL, and triglycerides
(described below). Cholesterol cannot travel through liquid (blood) on its own. It
needs carrier molecules, called lipoproteins, to carry it around. When we refer to
LDL-P, we refer to the number of lipoproteins carrying LDL within them. LDL-C, on the
other hand, is the concentration of cholesterol contained in those carrier proteins.
So, remember, Lipoproteins are the carrier molecules for cholesterol.

Total cholesterol- TC. This is a combination of LDL, HDL, and remnant lipoproteins
(VLDL and IDL). All this will be described below. When someone says their total
cholesterol is high, what does that mean? Does that mean their LDL is high? Their
HDL? Both? Knowing your total cholesterol is insufficient to make any health

DO I REALLY NEED TO WORRY ABOUT MY CHOLESTEROL?

assessments. We need to know the specifics of the individual types of cholesterol. In
addition, cholesterol is a vital component of our bodies, and is needed to
synthesize our hormones, to build cell walls, and to make nerve cells. Without
cholesterol, we die. Period.

LDL-C- The concentration of low density lipoproteins. LDL is frequently called the
“bad” cholesterol. In truth, LDL is a vital part of our bodies. LDL helps heal injuries
and respond to inflammation. LDL also helps transport energy to our tissues.
However, studies have shown that higher levels of LDL are associated with
increased risk of cardiovascular disease in the general population. Therefore, the
bad rap.

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 LDL-P- As stated above, the P refers to the particle number. This is not the total
concentration of LDL (that’s LDL-C). Instead, LDL-P refers to the number of LDL
carrying lipoproteins. This is a better maker of cardiac risk than LDL-C, but it is a
more expensive and more difficult test, so it is often not routinely checked.

HDL-C- The concentration of high density lipoprotein. The so-called “good”

cholesterol. HDL can transport cholesterol to the liver to be disposed of (reverse
cholesterol transport). Therefore, it was felt that anything that increases HDL would
lower cardiovascular risk. Reality says otherwise. Drug trials that increase HDL have
failed to show reductions in heart attacks or deaths. Naturally increasing HDL with
your lifestyle, on the other hand, does appear to correlate with reduced cardiac
risk. It is possible that HDL is more a reflection of healthy lifestyle and metabolic
health.

Triglycerides- TGs are the simplest form of fat fuel in your blood. Cells can use
triglycerides for energy, and whatever is not used can be stored as fat. Triglycerides

DO I REALLY NEED TO WORRY ABOUT MY CHOLESTEROL?

are also elevated in metabolic diseases such as insulin resistance and diabetes.

Remnant cholesterol- These are very low-density lipoproteins (VLDL) and

intermediate density lipoproteins (IDL). Essentially, they represent the cholesterol
that is not HDL or LDL and therefore can be calculated as TC-LDL-HDL. Remnant
cholesterol has been called the most harmful of all lipoproteins. It is rarely
measured, as drugs do not effectively reduce it.

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DOES LDL CAUSE HEART
DISEASE
Observational trials suggest a correlation between higher LDL levels and increased
risk of heart disease. Additionally, LDL particles are found in arterial plaques.
Therefore, it has been taught that LDL “causes” heart disease. This, however has

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been an assumption and not a proven fact. LDL responds to injury and
inflammation, just like fire fighters respond to a fire. That doesn’t mean they caused
the fire, even though you find them at just about every fire.

In addition, the observational studies average the data from thousands of people.
But if you are like me, you are not worried so much about thousands of people. You
are likely more concerned with you as an individual. Are there reasons for individual
variations? Yes!

It turns out that whether your LDL is “dangerous” or not, depends on other factors
that may be more important than the LDL itself. Some of the most important ones

DO I REALLY NEED TO WORRY ABOUT MY CHOLESTEROL?

are:

1. Smoking
2. Metabolic Health
3. Healthy Lifestyle
4. Inflammation

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 Smoking
This one is easy. Smoking is one of the most dangerous things you can do for your
heart health. Yet, smoking does not increase LDL. Instead, it increases the amount
of oxidized and inflamed LDL, so-called damaged LDL. It can also worsen
metabolic health (listed below). If you smoke and are worried about your LDL, you
are barking up the wrong tree. Quit smoking first. Then you can focus on LDL and
other risk factors.

DO I REALLY NEED TO WORRY ABOUT MY CHOLESTEROL?

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 Metabolic Health
Metabolic health refers to the presence of absence of insulin resistance,
prediabetes, and diabetes. Most commonly, those with poor metabolic health
have low HDL and elevated triglycerides. Studies show that elevated LDL (>220)
with good levels of HDL (high) and triglycerides (low), have a lower cardiovascular
risk than those with low LDL (<100) and poor levels of HDL (low) and triglycerides
(high). Said another way, if you have naturally high HDL and low triglycerides from

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your lifestyle and genetics, then your LDL is far less important.

In addition, studies have shown that using ratios such as TC:HDL and TG:HDL are
better predictors of cardiovascular disease risk than simply looking at LDL levels
alone. These ratios reflect metabolic health, whereas LDL alone does not tell us
anything about metabolic health.

To say it another way, if you have high triglycerides, low HDL, and insulin resistance,
then your LDL is more of a concern, and you should try to lower it. Even better,
however, would be to reverse your metabolic disease and improve your HDL and
triglycerides.

DO I REALLY NEED TO WORRY ABOUT MY CHOLESTEROL?

This is where our conventional medical thinking breaks down. LDL is high, therefore
give a statin to lower it. Quick and easy. And very short-sighted. Instead, we should
be addressing the main issues of metabolic health first, and then decide if the LDL
needs to be addressed once the other parameters are improved.

What makes this even more interesting is that most of the large trials associating LDL
and cardiovascular risk were done on people following the standard American diet
(SAD) or a low-fat, high-carbohydrate diet. These diets predispose people to
metabolic disease, and thus make their LDL more of a concern.

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 If the studies looking at LDL and cardiovascular risk were done on metabolically
healthy subjects without insulin resistance, following a healthy low-carb diet, then
we could guess the results would be much different.

DO I REALLY NEED TO WORRY ABOUT MY CHOLESTEROL?

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 Healthy Lifestyles
A trial published in NEJM investigated the risk of heart attack in those at highest
genetic risk and how that risk correlated with healthy lifestyles (defined as
maintaining a healthy weight, eating healthy, getting regular physical activity, and
not smoking).

They found that those who followed these healthy practices had up to a 50% lower

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risk of heart attack. Yet there was no meaningful difference in the LDL. They
reduced their risk by half, and had similar LDL numbers!

For them, the LDL was clearly not the issue. It was their lifestyle. Interestingly, they
also had lower triglycerides and higher HDL than the poor lifestyle group. This shows
the power of naturally raising HDL and lowering triglycerides. Not with drugs, but
with lifestyle.

DO I REALLY NEED TO WORRY ABOUT MY CHOLESTEROL?

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Inflammation
Similar to the trial mentioned above for metabolic health, different levels of
inflammation dramatically affect the risk of LDL. One trial showed that individuals
with LDL>160 and low levels of inflammation had a lower cardiovascular risk than
those with LDL<130 and high levels of inflammation.

Similarly, statin trials that show reduced inflammation markers also show the greatest
benefit. Those without a reduction in inflammation markers seems to have less
benefit.

Why does inflammation matter so much? Inflamed and oxidized LDL particles are
taken up by macrophages very efficiently, and these then turn into foam cells
which contribute to plaque instability and heart attacks. Healthy, non-inflamed LDL,
on the other hand, are not taken up well by macrophages, and therefore do not
have the same risk.

Remember, LDL is there for a reason. But we can “damage” our LDL simply by
creating a hostile environment of chronic inflammation.

DO I REALLY NEED TO WORRY ABOUT MY CHOLESTEROL?

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BUT WAIT. DOESN’T LOWERING LDL
AUTOMATICALLY SAVE LIVES?
Yep. I get this question every day as well. And it is a good one.

Once again, however, the data doesn’t support the hype. To cut to the punchline,
the best trials (all funded by drug companies), show that for primary prevention
(people who do not already have heart disease) we need to treat 60 people with a
statin for five years to prevent one heart attack. For those without any cardiac risk
factors, we need to treat over 200 people for five years. And here is the kicker.
There is no significant benefit for mortality. No lives saved. None.

That does not mean that statins don’t work. They do. They are one of the best
medications we have for reducing the risk of a heart attack. Notice I said
medications. What’s a better way to reduce your risk of a heart attack?
Maintaining good metabolic health, low levels of inflammation, eating well, getting
regular physical activity, managing our stress…in short- living a health life!

DO I REALLY NEED TO WORRY ABOUT MY CHOLESTEROL?

But wait….there’s more as the nuance continues.

All the statin trials were done on subjects eating a standard American diet or a low-
fat diet. As we have seen before, that is frequently correlated with insulin resistance,
high triglycerides and low HDL. These are all factors that increase the risk of LDL.
Would the same statin benefit hold true for healthy individuals with low triglycerides
and high HDL? That is not known. But there is plenty of reason to believe that it
would be a different story.

And finally, remember that statins do far more than lower LDL. They reduce
inflammation, have anticoagulant properties and more. Do they work because
they lower LDL? Or do they work by other means and they happen to also lower
LDL? That is unproven, but sure is a great question

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STILL, LDL DOES TRACK WITH
CARDIOVASCULAR DISEASE
A study in JACC tried to address the issue of LDL and cardiovascular risk in healthy
individuals. They found evidence of vascular plaque increased as LDL increased.
Looking at the conclusion, it seems clear that LDL is a key risk factor for developing
cardiac plaque. So again, it is not that LDL is completely unimportant.

But there is a glaring fault in this study. They defined “healthy” individuals as having
blood pressure <140/90, and fasting blood glucose <126. By definition, that means
their “healthy” people had stage I hypertension and pre-diabetes. Is that your
definition of healthy? I sure hope not.

DO I REALLY NEED TO WORRY ABOUT MY CHOLESTEROL?

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WHAT CAN WE CONCLUDE FROM
ALL THIS?
If you have insulin resistance, have high levels of inflammation, have low HDL and
high triglycerides, then an elevated LDL is very concerning. You may want to take
steps to lower your LDL. More importantly, however, would be to improve your
metabolic health, reduce your inflammation, and naturally increase your HDL and
reduce your triglycerides.

Of course, there are other factors we need to consider such as family history, blood
pressure, coronary calcium score and more. Decisions still need to be individualized
for you with your doctor.

As you can see, however, the risk of cholesterol is not the same in all individuals. The
advice to lower LDL in everyone is short-sighted and potentially dangerous for
many. Instead, we need to demand that our healthcare providers give us the
individual attention we deserve, and not treat us as a general statistic. We deserve

DO I REALLY NEED TO WORRY ABOUT MY CHOLESTEROL?

nothing less.

Questions or comments? Please let us know at www.LowCarbCardiologist.com.

Browse through our blog, listen to our podcast, or even sign up for a one-on-one
consultation with me. Most importantly, let us know how we can help you on your
health journey.

Bret Scher, MD FACC

Founder, Boundless Health
www.LowCarbCardiologist.com

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Bret Scher, MD FACC
Founder, Boundless Health
www.LowCarbCardiologist.com