Cholesterol: So you are an expert too?! – Part 1

I have a bone to pick today. And I am going to pick it.

In the current nutritional climate where information, misinformation and everything in between is rife, it is really difficult to know who we can trust as the “real experts”.

There has been a long standing Cold War between different health professions – Physios can’t stand Chiros; Conventionally-Trained Doctors can’t stand Traditional Chinese Medicine Doctors; Dietitians can’t stand Nutritionists; and no one can stand Homeopaths… #sorrynotsorry

But at the end of the day – why is this happening?

I’ll tell you why. It is all because of 3 little letters – E-G-O.

Ego.

Honestly – when did ego ever save a life? When did ego ever help science progress? When did ego ever let YOU progress?

Yet, everyone has one, and everyone loves to whip it out and compare it to the next person’s. “My qualification is better than yours” is the argument we hear and see over and over again. But qualifications alone mean very little.

Over the years, I have encountered many health professionals – mostly doctors and dietitians – who have proclaimed to be experts in Heart Disease and Cholesterol Management. If you do a Google search, you will see exactly what I mean – everyone claims that they are an “expert in” or “specialises in” Heart Disease and Cholesterol. But how many of these “experts” are real experts in these areas?

Well I guess our first pit stop is to define the word “expert”.

According to the Oxford definition, an expert is someone who is “very knowledgeable about or skilful in a particular area”.

Now this is where things start to fall apart. You see, when you ask a lot of these “experts” about Heart Disease and Cholesterol, they will state (almost in unison) that you need to maintain your Cholesterol below 5.5mmol/L and that eating more Saturated Fats will clog your arteries and lead to higher LDL cholesterol (the “bad” cholesterol) and an increased risk of Heart Disease.

[The reason why I make a point of pointing out that this is “almost in unison” (apart from clearly identifying that I do not echo their sentiment) is because the general impression is “surely if there are so many people who share the exact same views, then it MUST be the correct information. Right?” WRONG.]

The aforementioned statement that a lot of these “experts” make is the very reason why they are NOT experts and why I have this massive bone to pick today.

People get their Cholesterol levels checked by their GPs by the swarms each day, and this test itself has almost become an indispensable part of their routine blood workups. However, why is it that I see clients who have terrible lipid profiles not having their Cholesterol addressed (or have it addressed in a non-expert way that only leads to these numbers worsening), and why is it that I equally see clients who have always had great lipid profiles being put on Statin medication when there is no real indication for it?

This comes down to the “experts” knowledge and skill in interpreting pathology and knowing what to do to manipulate pathology in favour of the clients’ Heart Health.

So today, let’s have a Master Class on Cholesterol Pathology Interpretation. By the end of this, I hope that you (if you are a client) will no longer sit there blindly nodding at your blood test report, not knowing what means what; and I hope that you (if you are an “expert”) will no longer be misleading your clients in how their bloods are actually performing against their risk of developing Heart Disease.

This is going to get quite scientific, so hang in there!

In order to begin this Master Class on Cholesterol, I think it is best to set the scene for what Cholesterol actually is and what it actually does in the body. For so long, people have cowered at the word “Cholesterol” but never really understood even themselves why they act that way.

Cholesterol is literally defined as “bile solids”. In our body, most of the bile salts are made from cholesterol, and without this, we would not be able to absorb any fats. Cholesterol is also an integral structural component in all our cell membranes, it forms the precursor of Vitamin D, and, it is directly responsible for producing steroidal hormones such as testosterone, progesterone and cortisol. As you can see, without Cholesterol, we’d all be in a bit of strife…

So why is it then that we are all so afraid of something so essential to life?

It may have something to do with all the “experts” perpetuating the same WRONG information around what your Cholesterol levels actually mean.

Let’s take a look at 2 different Pathology reports (I encourage you to get yours out so we can go through it together too):

So, which one is better – Sample A or Sample B? Who is at a lower risk of Heart Disease? Read on to find out.

Total Cholesterol

This means nothing. A healthy individual will have Cholesterol in the blood. Depending on many factors, this could be higher or lower, but ultimately this number alone has ZERO implications on your risk of Heart Disease. And frankly, if you had none, you’d be dead.

Take Home Message: Stop placing so much emphasis on this number. At the end of the day, it means very little.

Triglycerides

Triglycerides rise in the blood when excess carbohydrates are consumed, especially an excess of fructose in combination with glucose.

This happens because when muscle glycogen levels are full, glucose enters the liver. Fructose cannot be taken up by your muscles in any capacity, and it goes directly into the liver. Because of this build up of sugars in the liver, the body converts it to Triglycerides.

These Triglycerides are then exported from the liver in a large particle called VLDL (Very Low Density Lipoprotein). For the sake of this article, I will refer to VLDL as a “big ball of Triglycerides”.

This big ball of Triglycerides will then go on to interact with HDL (High Density Lipoprotein) via a process called CETP and gives up Triglycerides in exchange for Cholesterol. This process wears out the HDL.

As a result, in people with high Triglyceride levels, their HDL levels will always be lower.

Take Home Message: Triglycerides and HDL are inversely related – when Triglycerides are high, HDL is low; when Triglycerides are low, HDL is high.

HDL

This has widely been considered the “Good” Cholesterol. This is because, as explained above, if HDL is high, then our Triglycerides will inevitably be low.

So why is it a good thing if Triglycerides are low (or for that matter, if HDL is high?)

I go on to explain this later.

Take Home Message: We want HDL to be high (and by association, we want Triglycerides to be low).

LDL

LDL (Low Density Lipoprotein) is a NATURAL by-product of fat metabolism. Although this is widely referred to as “Bad” Cholesterol, it certainly does not deserve this title. Let me explain.

In normal fat metabolism, our big ball of Triglycerides (VLDL) will travel through our blood, offloading triglycerides, and swapping it for cholesterol. By the time it becomes LDL, the particle is now mostly cholesterol, as the triglycerides have all been swapped out.

Under normal circumstances, LDL will go straight back to the liver. However. If there is a LOT of triglyceride to exchange, the LDL will be parked in the blood for longer, leaving the LDL open to oxidisation and glycation, both processes changing the inherent structure of the LDL, and it becomes small and dense and sticky, known as sdLDL (Small Dense LDL…duh!). Because of this, the liver no longer wants it back.

Take Home Message: LDL is not inherently bad. However, when it stays in the blood for longer than it should, it becomes small and dense and this small, dense LDL is what increases your risk of heart disease.

So what happens to this sdLDL?

Our body has natural scavengers known as Macrophages. These macrophages go around and suck up these sdLDL. Unfortunately, if there is a lot of these sdLDL, the macrophages become engorged on it, and this forms what we commonly know of as “plaque”. Being small and dense, sdLDL can easily get caught in the blood vessel walls, and as macrophages gorge on sdLDL, these plaques start to form on the blood vessel walls.

Take Home Message: If given the opportunity to stay in the blood for longer, normal LDL becomes oxidized and glycated, and turns into sdLDL. This sdLDL is what directly increases your risk of Heart Disease.

Can we test for sdLDL?

The answer is yes. You can get LDL-P size testing done, but there are only a couple of labs that do it in the whole of Australia. In the absence of direct particle size testing, we can always predict it using 2 known figures: Triglycerides and HDL.

When Triglyceride levels in the blood are HIGH (meaning >1.5mmol/L), sdLDL are almost always present. We also know that when Triglyceride levels are LOW (<1.0mmol/L), the LDL is almost always the large fluffy kind, not the small, dense kind.

THIS is why we want triglyceride levels in the blood to be low, as it directly reflects the type of LDL you have in your blood, and your risk factor for Heart Disease.

However, statistically, Triglyceride levels are not very consistent or reliable. So what do we do? We look at our HDL levels. HDL is much more consistent and reliable as a statistical marker.

Take Home Message:

If HDL is high, Triglycerides are low.

If Triglycerides are low, sdLDL is low.

And when sdLDL is low, your risk of Heart Disease is LOW.

So when you next look at your blood lipid profile – you won’t have to sit and stare blankly anymore. You can follow these steps instead.

1. Make sure that your Triglyceride are low (less than 1mmol/L)

2. Make sure your HDL is HIGH (whatever it takes for Triglycerides to be less than 1mmol/L)

3. Stop looking at Total Cholesterol – it means NOTHING

4. Stop letting people tell you that LDL is the “bad” cholesterol

a. The small dense kind, yes

b. The large fluffy kind, no

And how do you know which is which? Go back to Step 1.

And THAT is how you Interpret your Cholesterol levels in relation to your risk of Heart Disease.

So the BIG QUESTION now is…..what foods increase Triglycerides and decrease HDL, and which ones do the exact opposite (which is what we want!)?

Stay tuned for Part 2 where I go into all things food.