Dr Philip Bhark - CholesterolDoes the word cholesterol evoke a yucky feeling in you? Similar to an uninvited relative who shows up at your doorstep with an inappropriate grin? Or perhaps a tax collector who you definitely don’t like to be friends with but nevertheless have to learn to get along with? TV commercials capitalize on this unhappy relationship by portraying cholesterol as a bothersome character, dressed in a yellow skin-tight garb including a hood (a la Woody Allen’s “sperm cells”) who lurks around your kitchen taking all the fun away from your enjoyment of food.

To be fair, we wouldn’t be alive without cholesterol. It forms the foundation for all our sex hormones, is an essential unit of our cellular structure and function, forms bile and vitamin D, just to name a few. It is made endogenously (internal origin) by the liver and other organs, the amount depending on your exogenous cholesterol intake. Our current problem with food arises from too much availability rather than too little, as it was for our ancestors many millennia ago. Cholesterol production, absorption, transportation, uptake by cells, its journey back to the liver, degradation, elimination are more complicated than we wish to know or to understand. Therefore, we have taken short cuts and have labelled two primary cholesterol carriers as HDL (so called good cholesterol transporter) and LDL (aka “bad” cholesterol carrier). In fact, most of the beneficial aspects of cholesterol is carried out by LDL. The problem comes when we have excess amounts of LDL or when we do other harmful things to ourselves (such as smoking cigarettes, building up large amounts of free radicals through unhealthy foods, poor intake of vitamins and other nutrients, stress, etc.) whereby the LDL becomes oxidized or unstable, which in turn makes it easier to enter into blood vessel walls. Once inside the wall, it can attract many other agents, eventually forming a fatty plaque, known medically as atherosclerosis or more commonly in the streets as “clogging of the arteries”.

HDL has a good reputation because one of its primary role is to pick up used cholesterol particles, as a garbage collector would, and return them to the liver for excretion. Thus more HDL you have, the cleaner the streets (blood vessels). It is important to know that while an unstable LDL can leach into your blood vessel wall, by making them stable again through exercise, good nutrition and so forth, LDL can equally be removed from blood vessel walls. Thus, plaque formation is not an irreversible, one way street.

HDL, besides its clean up role, has many other salutary effects, which we are only now beginning to understand and appreciate. For example, it mitigates inflammatory response, is related to thinning of the blood, has a direct and indirect positive effect in keeping the arterial walls healthy, delays cell death, and prevents LDL oxidation.

Thus, we need to try to keep our LDL levels low and HDL levels high. The former is accomplished with a prudent diet (low in animal fat and high in fibers), with or without natural remedies for lowering cholesterol such as red yeast rice. It is equally important to raise the HDL since independent of LDL, HDL predicts cardiovascular risk events. For us living in Thailand, we have easy access to organic virgin cold pressed coconut oil which will raise the HDL. Other means include exercise, niacin (vitamin B3), weight loss, mild to moderate alcohol intake, while obesity, sedentary life style, diabetes, infections, malnutrition will lower HDL levels.
Why are all these measures necessary? There are definite correlations between LDL, HDL levels and our risk for sustaining a cardiovascular event (heart attack, stroke or some other form of vascular disease). But it isn’t simply a matter of “numbers game”. The picture gets confusing in part because there are many different subtypes of LDL and HDL particles, numbering in the hundreds. Some subtypes are thought to be particularly harmful (such as the small, densely packed LDLs) while others are quite beneficial (such as the large HDL2s). Thus many with “elevated” cholesterol levels live normal healthy lives while over half of the folks who suffer a heart attack have “normal” cholesterol profile. Besides the specific type of LDL and HDL as well as the total numbers, your risk depends on so many other factors such as hypertension, obesity, exercise routine, genetics, stress effects and so on. Risk factors are algorithmic and not additive, and therefore it makes sense to reduce them as best as we can. For those of you who have already had a significant cardiovascular event, you belong to an entirely different group. You need to do all you can to improve your HDL (keep it at 50 or above) and your LDL (less than 100). If it means having to take strong medications, I would recommend you do so since you have already demonstrated that you do have “clogged arteries”. Remember, you can reverse some of the damage done to the blood vessels walls by taking appropriate steps.

Finally, few additional points to consider. If your cholesterol is elevated and you are puzzled by it since you take exceptional care of yourself, please consider other causes of elevated cholesterol such as thyroid, liver or kidney disease, or genetics. Also, a fanatic low fat diet can have a reverse effect, sending the wrong message to your liver that you are starving, which in turn will crank up its cholesterol production. There is also a casual relationship between low cholesterol and cancer. Increasing evidence is now in, suggesting a forward link between low cholesterol and cancer formation but not the other way around. That is, cancer does not appear to be the cause of low cholesterol. This information is worth considering for several reasons. One, many of my cardiology colleagues take potent cholesterol lowering medications, despite the absence of any evidence that they have a cardiovascular disease. I think it shows poor judgement. For a healthy individual, the risk reduction by taking a lipid lowering medication long term would be about two percent. The risk of developing diabetes from taking these potent medications, especially at higher does long term, is about half a percent. Diabetes is currently classified as an equivalent to a “clogged artery”. If you do the math, it makes sense that we avoid taking cholesterol lowering meds if we are otherwise healthy and with no other significant risk factors.

To summarize, do your best to keep the “numbers” within a reasonable range as you enjoy your life. (For you compulsive, need to know folks, you can, for an extra expense, get detailed analysis of your cholesterol profile.) Work harder if you’ve already had a cardiovascular event. Remember, heart attacks are preventable! I am currently in France with my wife, visiting her family and friends. My cholesterol will undoubtedly rise for the moment but I promise to keep close tabs on it.

Have fun!
Dr. Philip Bhark M.D., FACC

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