First off, there is no such thing as ‘good’ or ‘bad’ cholesterol, frequently referred to as HDL and LDL respectively.
Should you be worried if your TOTAL Cholesterol is more than 200mg/dL (5.17 mmol/L)? It depends. You need to look at your HDL and triglycerides numbers. Use the following logic to determine if you need to do something. (If the following looks like a computer program, that’s because I am a Computer Science graduate)
If TOT CHOL > 200, check your triglycerides
If triglycerides <= 45 mg/dL (0.5 mmol/L), you are OK
If triglycerides > 45 mg/dL (0.5 mmol/L), check your HDL
If HDL >= 58 mg/dL (1.5 mmol/L), you are OK
If HDL < 58 mg/dL (1.5 mmol/L), check your triglycerides/HDL ratio
If triglycerides/HDL ratio <= 1.8 mg/mg (0.8 mmol/mmol), you are OK
If triglycerides/HDL ratio > 4 mg/mg (1.8 mmol/mmol), you need to do something to improve your cholesterol levels. You many follow the recommendations in Jake’s Formula to lower your triglycerides and raise your HDL.
If triglycerides/HDL ratio is in between the 2 numbers above, you need a further test (NMR) to determine if your LDL is the good fluffy pattern A or bad small dense pattern B.
In order to understand how diet (especially carbohydrates and polyunsaturated fats) affects your blood cholesterol, it will be good to have an understanding of what cholesterol is. Read on.
Cholesterol is a substance that is present in all the cells in our body! Approximately 25% of the total amount of cholesterol in our body is found in the brain. It is such an important component that our brain produces its own cholesterol. Hence if you want better brain health, load up on healthy fats. (Read my section on Saturated Fats)
Our body produce roughly 3000mg of cholesterol daily. Cholesterol is needed to make hormones, such as our sex hormones, and other important compounds such as vitamin D.
There is no scientific evidence that cholesterol by itself blocks coronary or cerebral arteries, causing heart attacks or strokes. There is only a weak association between the amount of cholesterol in a person’s diet and the level of blood cholesterol in the body. As such, there is no need to avoid foods that contain cholesterol, such as eggs and liver. (Ref A) As a result, the 2015–2020 Dietary Guidelines for Americans on restricting dietary cholesterol to 300 mg/day has been removed.
Let me give an example with eggs. In a study of overweight men consuming a carbohydrate-restricted diet, these men were split into 2 groups: 1 group eating 3 eggs/day and the other none. After 12 weeks, all of them reduce in weight and waist circumference and triglycerides. There was a greater increase in HDL among the 3eggs/day group compared to no egg group. There was no difference in LDL. (Ref C)
Although cholesterol is present in arteriosclerosis, they are not the root cause of the disease. As an analogy, when there is an accident, you will see policemen at the scene. They are not the cause of the accident. They are there to help. Similarly, LDL is trying to carry the cholesterol (the raw materials) to your arteries to fix the problem. Cholesterol, calcium and other substances are carried to the damaged arterial walls in order to fix the damage. This is usually in response to damage caused by elevated blood glucose and insulin. Cholesterol in the arterial walls is the result of arterial injury, not the cause.
Cholesterol and triglycerides do not mix with water in the bloodstream. As such, they need lipoproteins (VLDL, LPL, HDL etc) to carry them along the bloodstream so that they can be delivered to the cells which need them.
Studies of older people show that the higher your cholesterol levels in later life, the less likely you are to get dementia. The cerebrospinal fluid of people with Alzheimer’s Disease is lower in cholesterol than healthy non-dementia people of the same age. Higher cholesterol levels are associated with better cognitive abilities in older people.
In the Leiden 85+ study, a similar mortality risk (that means no difference) was found in all 3 groups of participants according to total cholesterol (<200 mg/dl, 200 – 249 mg/dl, and ⩾ 250 mg/dl). Mortality from cancer and infection was significantly lower among the participants in the highest total cholesterol category than in the other categories. (Ref B)
In the Lothian Birth Cohort study to find out if cholesterol predicted cognitive function, the highest cholesterol group (> 241 mg/dl) has the lowest percentage of hypertension, stroke and heart disease. This group also has the highest general cognitive ability, processing speed and memory. (Ref B)
Excess cholesterol in the blood gets eliminated through the gut into the faeces.
How to interpret the numbers in your lipid profile blood test
Now let me go into the usual 5 numbers you see in your lipid profile during your medical check-up.
Total Cholesterol – This is the total number which includes High-density lipoprotein (HDL), Low-density lipoprotein (LDL) and very-low-density lipoprotein (VLDL). Although the optimal is <200 mg/dL or <5.2 mmol/L, it is not useful because if your HDL is much higher than your LDL, which is good, the total might be above 200, which is telling you it is not good. Doesn’t make much sense right? This shows that we need a better indicator other than TOT cholesterol.
HDL – the conventional ‘good’ cholesterol. HDL looks for excess cholesterol from the bloodstream and artery walls and ferry it back to the liver for recycling or removal.
The higher your HDL, the better. So anything >60 mg/dL or >1.6 mmol/L is optimal. HDL particles remove fats and cholesterol from cells, including within artery wall atheroma, and transport it back to the liver for excretion or re-utilization; thus the cholesterol carried within HDL particles (HDL-C) is sometimes called “good cholesterol”.
LDL – the conventional ‘bad’ cholesterol. LDL carry cholesterol from the liver to the rest of the body.
The optimal range is <100 mg/dL or <2.6 mmol/L. The number you get from a normal blood test is measuring the amount of LDL in the blood. Currently, a better matric to measure is the number of LDL particles (LDLp) which seems to be more useful in determining if there are any issues with your LDL. But I will not talk about this here.
LDL is involved in our immune system as discussed at the beginning of this section. It helps us to fight infections by neutralising the quorum sensing accessory gene regulator protein from the bacteria and stops the bacteria from multiplying. You may watch this video to learn more about the functions of LDL. https://www.youtube.com/watch?v=NNo5tAsaUzI Functions of LDL CHOLESTEROL | Dr Nadir Ali
After dropping the triglycerides and cholesterol, LDL particles are absorbed via the LDL receptor in the liver and recycled in the liver.
There are 2 kinds of LDL, pattern A or B. Pattern A is the big and fluffy ones that are good. Pattern B are the small and dense ones which are considered bad as it can get stuck within arterial walls. One way to determine which pattern you have is to check your lipid numbers against the following flow diagram, which is the same as the logic presented at the beginning of this section.
If any of the 3 leads to a ‘YES’, it means your LDL is most likely Pattern A. If all the answers give you ‘NO’s, you might want to do a further test, called the NMR test, to determine which kind of LDL particles you have predominantly. The NMR LipoProfile test is an advanced cardiovascular diagnostic test that uses nuclear magnetic resonance (NMR) spectroscopy to provide rapid, simultaneous and direct measurement of LDL particle number and size of LDL articles, and also direct measurement of HDL and VLDL subclasses.
25 years ago, William P. Castelli, the Framingham director – of the biggest heart study ever done – indicated that “unless LDL levels are very high, 7.8mmol/L (300 mg/dL) or higher – they have no value, in isolation, in predicting those individuals at risk of CHD” The standard has since been lowered to 130mg/dL or 3.36mmol/L. This effectively puts many people in the ranks of ‘high’ LDL-C and the need to take cholesterol lowering drugs.
Triglycerides (TRIG) – These are formed by 3 molecules of fatty acids. They are the energy from fats to be carried by very low density lipoprotein (VLDL) to feed our cells. After delivering the energy, these VLDL becomes LDL. Conventional optimal range is <150 mg/dL or <1.7mmol/L.
TOTal Cholesterol/HDL ratio – the Total Cholesterol to HDL ratio is used to predict risk of heart disease.
- 5.0 = average risk
- 3.4 = half the average risk
- 9.6 = twice the average risk
- 4.4 = average risk
- 3.3 = half the average risk
- 7.0 = twice the average risk
“The Total/HDL ratio was found to be a better predictor of CHD than TC, LDL, HDL and TRIG – not only in the Framingham Study, but also in the Physician’s Health Study and many other studies.” William P. Castelli
TRIG/HDL ratio – the triglycerides to HDL ratio is a very good predictor of coronary heart disease, a lot better than LDL itself. Although this ratio is usually not found in your lipid profile, you can calculate this ratio easily by dividing your triglycerides number over HDL. To convert your triglycerides mmol/L to mg/dL, multiply by 88.57. To convert HDL mmol/L to mg/dL, multiply by 38.67.
A ratio as close to or less than 1.0 is optimal, meaning your risk of heart disease or stroke is very minimal. (For your reference, mine is 0.5)
If your ratio is >3.75 (mg/dl/mg/dl) for men and >3.00 (mg/dl/mg/dl) for women, corresponding to 1.64 (mmol/L/mmol/L) for men and 1.31 (mmol/L/mmol/L) for women, your risk of heart attack and stroke is greatly increased.
As you can see from the graph, there is a very small difference of 1% in rate of ischemic heart disease(IHD) using LDL alone. However, if you use Trig/HDL ratio, those in the high group (Trig ≥ 176 mg/dL & HDL ≤ 46 mg/dL or ratio >3.82) are 2X more at risk of IHD than the low group (Trig ≤ 112 mg/dL & HDL ≥ 60 mg/dL or ratio <1.87).
By looking at just high or low LDL, there is not much difference in the risk of CHD. But when you use Total Chol/HDL, those in the high group (ratio > 5) have double the risk of CHD compared to those in the low group (ratio <= 5). (IR= Insulin Resistance). It might be interesting to note that those with High LDL are at a lower risk within the same Total Chol/HDL group.
Above illustrations taken from The Fat Emperor Podcast by Ivor Cummins: What’s the Real Story with Cholesterol and Heart Disease? Podcast Ep9 https://www.youtube.com/watch?v=9N7CvW1Jqes&t=49s
How do your blood markers respond (up or down) when you are on a low-carb diet?
HDL, LDL goes up.
Triglycerides, glucose, insulin, inflammation, go down. blood pressure, weight
Cholesterol lowering drugs – statins
Statins are the most profitable drug in history. The big pharmacies are pushing for doctors to prescribe this drug by lowering the cut-off for Total Cholesterol (200mg/dL) and LDL (130mg/dL). Once any of these markers is exceeded, your doctor will prescribe a statin to lower your cholesterol to decrease your risk of heart attack. But in the first place, cholesterol DOES NOT increase your risk of heart disease, as I have detailed above. You cannot just use either the TOTAL cholesterol or LDL number alone. You need to look at your other blood markers.
A study showed that statin use did not improve cardiovascular benefits while doubling the odds of getting diabetes and diabetic complications among people who are physically active. (Ref E) Another study showed that it is more beneficial to exercise than to take a statin if you encounter muscle pain as side effects. (Ref F). This means that if you have slightly higher than normal LDL (between 130mg/dL to 200mg/dL), it is better for you to get physically active than to take a statin.
However, statins might be useful for those who have already suffered an event, either a heart attack or stroke. For those who have not encountered any heart event, 3% of those not taking a statin will have a heart attack compared to 2% of those who took a statin. The big pharmacies are down-playing the side effects by funding research studies to skew the results.
For example, let’s take an advertisement for one of the statins, Lipitor, shown here. Pfizer is the company who developed this drug. The generic version of Lipitor is Atorvastatin.
If you noticed the asterisk beside the 36%, the fine prints at the bottom left states * That means in a large clinical study, 3% of patients taking a sugar pill or placebo had a heart attack compared to 2% of patients taking Lipitor.
So you might wonder how did a 1% difference become a whopping 36%? Well, here is the actual data from the study (Illustration taken from the talk by David Diamond which I shared on my home page)
Computation: (98.1 – 97) / (100 – 97) = 1.1 / 3.0 = 36%. If a drug company has to resort to using relative effects to blow up the absolute effects of its drug in its advertising, something is not right. Will you even bother about taking a drug that is only 1% effective in reducing your chance of a heart attack but you might end up suffering the side effects that come with it? Here is a piece of news related to this advertisement. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2265337/
If your doctor is recommending a statin to you to lower your cholesterol and you do not have a heart event yet, should you or should you not take it? I refer you to the following videos and you can decide for yourself after watching them.
Dr. Maryanne Demasi – ‘Statin Wars: Have we been misled by the evidence?’
Too Much Medicine & The Great Statin Con – Dr Aseem Malhotra
Do statins prevent or cause heart disease? Dr Nadir Mir Ali
Total Cholesterol and LDL are not useful in predicting heart attack risks. The better indicators are Total Cho/HDL ratio and TRI/HDL ratio. If your HDL is high and TRIG is low and you are not insulin resistant, a high LDL means you will live longer, be smarter, have better memory, have a lower infection rate and your recovery from infections will be much faster. This is my current state of health. And you can have it too. Just go to Jake’s Formula page to find out more.
(Ref A) Kratz, M. (2005). Dietary cholesterol, atherosclerosis and coronary heart disease. In Atherosclerosis: Diet and Drugs (pp. 195-213). Springer, Berlin, Heidelberg. https://link.springer.com/chapter/10.1007/3-540-27661-0_6
Soliman G. A. (2018). Dietary Cholesterol and the Lack of Evidence in Cardiovascular Disease. Nutrients, 10(6), 780. https://doi.org/10.3390/nu10060780
(Ref B) Dr. Nadir Ali – ‘Why LDL cholesterol goes up with low carb diet and is it bad for health?’ https://www.youtube.com/watch?v=qXtdp4BNyOgFrom 12:27 to 14:10)
(Ref C) Mutungi, G., Ratliff, J., Puglisi, M., Torres-Gonzalez, M., Vaishnav, U., Leite, J. O., Quann, E., Volek, J. S., & Fernandez, M. L. (2008). Dietary cholesterol from eggs increases plasma HDL cholesterol in overweight men consuming a carbohydrate-restricted diet. The Journal of nutrition, 138(2), 272–276. https://doi.org/10.1093/jn/138.2.272
(Ref D) Dr. Paul Mason – ‘Blood tests on a ketogenic diet – what your cholesterol results mean’ https://www.youtube.com/watch?v=DXKJaQeteE0&t=1268s (From 20:54 to 21:25)
(Ref E) Mansi, I. A., English, J. L., Morris, M. J., Zhang, S., Mortensen, E. M., & Halm, E. A. (2017). Statins for primary prevention in physically active individuals: Do the risks outweigh the benefits?. Journal of science and medicine in sport, 20(7), 627-632.
(Ref F) Bosomworth, N. J. (2016). Statin therapy as primary prevention in exercising adults: best evidence for avoiding myalgia. The Journal of the American Board of Family Medicine, 29(6), 727-740.