Cholesterol has long been a hot topic of concern in the health world, often vilified as a primary culprit in heart disease. However, as a holistic nutritionist, I believe it's crucial to understand cholesterol's role in our bodies and approach it from a more holistic perspective. Let's dive into everything you need to know about cholesterol.

First of all: What is Cholesterol?

Contrary to popular belief, cholesterol isn't inherently bad. It's a waxy substance produced by the liver and found in every cell of the body. Cholesterol plays vital roles in hormone production, vitamin D synthesis, and maintaining cell membrane integrity. To highlight its importance, when someone eats a very low-fat (& low-cholesterol) diet, it can hinder proper hormone production interfering with testosterone, estrogen, and progesterone production.

Contrary to popular belief, dietary cholesterol is not the primary source of cholesterol in the body for most people. Approximately 80% of the cholesterol in your body is produced by your liver. Only about 20% of the cholesterol in your body comes from the foods you eat.

What are HDL and LDL Cholesterol?

Understanding "Good" and "Bad" Cholesterol

Imagine your blood as a busy highway. Cholesterol travels on this highway in two main types of vehicles:

1. HDL - The "Good" Cholesterol:
   • This of HDL as tiny cleaning truck.
   • They drive around your body, picking up extra cholesterol.
   • They take this cholesterol to your liver, which gets rid ofit.
   • More of these cleaning trucks (higher HDL) is generally good for you heart.
2. LDL - The "Bad" Cholesterol:
   • Picture LDL as dump trucks that can cause traffic jams.
   • Too many of these can drop off cholesterol in your blood vessels.
   • This can create "roadblocks" in your arteries, which isn't good for your heart.
   • Fewer of these dump trucks (lower LDL) is usually better for your health.

For a long time, doctors have been checking the number of these "good" and "bad" trucks to guess your heart health. But now, they're finding that counting a special label on all the "bad" trucks (called ApoB) might give a more accurate picture of your heart risk.

Understanding ApoB: A Better Way to Check Your Heart Health

ApoB is a special protein found on particles in your blood that can cause heart problems. These harmful particles are alled atherogenic lipoproteins - including LDL, very-low-density lipoprotein (VLDL), and lipoprotein(a)). Think of ApoB like a sticker - each harmful particle has one ApoB sticker on it. By counting these stickers, doctors can tell how many risky particles are floating around in your blood.

Why is ApoB better than the usual cholesterol tests?

1. It counts the actual number of harmful particles, which tells us more about your heart disease risk.
2. It includes all types of risky particles, not just LDL cholesterol.
3. It may be a better measure in people with metabolic syndrome, diabetes or obesity.

A good ApoB level is usually below 80, while above 120 is considered high risk. Some doctors prefer even lower levels for better health.

Here's the key takeaway:

• If your LDL levels are considered high but your ApoB is low, your risk of heart disease may be low.
• If your LDL look fine but your ApoB is high, you may be at a higher risk and should talk to your doctor.

So, ApoB gives a clearer picture of your heart health than traditional tests. It's like having a more accurate radar for spotting potential problems.

What are the Normal and Optimal Cholesterol Ranges on Bloodwork?

In both Canada and the United States, cholesterol levels are measured in milligrams per deciliter (mg/dL) or millimoles per liter (mmol/L). Here are the generally accepted ranges:

Total Cholesterol:

• Optimal: Less than 180 mg/dL (4.65 mmol/L)
• Desirable: Less than 200 mg/dL (5.2 mmol/L)
• Borderline high: 200-239 mg/dL (5.2-6.2 mmol/L)
• High: 240 mg/dL (6.2 mmol/L) and above

LDL Cholesterol:

*Need to look at the number and size of LDL cholesterol particles (lipoprotein fractionation) to determine if cholesterol is atherogenic or benign

• Functional Medicine Optimal: Less than 70 mg/dL (1.8 mmol/L)
• Optimal: Less than 100 mg/dL (2.6 mmol/L)
• Near optimal: 100-129 mg/dL (2.6-3.3 mmol/L)
• Borderline high: 130-159 mg/dL (3.4-4.1 mmol/L)
• High: 160-189 mg/dL (4.1-4.9 mmol/L)
• Very high: 190 mg/dL (4.9 mmol/L) and above

HDL Cholesterol:

• Low: Less than 40 mg/dL (1.0 mmol/L) for men, less than 50 mg/dL (1.3 mmol/L) for women
• Optimal: 60 mg/dL (1.6 mmol/L) and above

Root Causes of Cholesterol Imbalance

As a holistic nutritionist, it's crucial to address the root causes of cholesterol imbalances rather than just jumping to a statin. Several underlying factors can contribute to unhealthy cholesterol levels:

1. Chronic Inflammation: Ongoing inflammation, whether from autoimmune conditions, poor diet/lifestyle, infections or disease, in the body can disrupt the way your body breaks down HDL and LDL and contribute to the formation of oxidized LDL cholesterol, which is particularly harmful to cardiovascular health.
2. Sluggish Thyroid (Hypothyroidism): An underactive thyroid gland can lead to increased LDL cholesterol levels and decreased HDL cholesterol, affecting overall cholesterol balance.
3. Insulin Resistance (poor blood sugar balance): When cells become resistant to insulin, it can trigger increased production of cholesterol and triglycerides in the liver, leading to imbalanced lipid profiles.
4. Genetic Mutations: Some people have genetic variations that can affect how the body processes cholesterol, leading to persistently high levels (this is called familial hypercholesterolemia).
5. Nutrient Deficiencies: Lack of essential nutrients like magnesium, vitamin D, and omega-3 fatty acids can impact cholesterol metabolism and overall cardiovascular health.
6. Menopause: Menopause can significantly impact cholesterol levels due to the decline in estrogen, which plays a protective role in regulating lipid metabolism. As estrogen decreases LDL tends to increase and HDL may decrease slightly, further reducing cardiovascular protection.

Understanding these root causes allows you to take a more targeted approach to managing cholesterol levels.

Lifestyle Factors Affecting Cholesterol

Cholesterol levels are also influenced by various lifestyle factors:

1. Diet: While dietary cholesterol has less impact than once thought, the types of fats can matter. Focus on incorporating healthy fats from sources like avocados, nuts, seeds, and olive oil.
2. Exercise: Regular physical activity can help increase HDL cholesterol and improve the ratio of LDL to HDL.
3. Stress: Chronic stress can negatively impact cholesterol levels. Incorporate stress-management techniques like meditation, yoga, or deep breathing exercises.
4. Sleep: Even poor sleep quality can disrupt cholesterol metabolism. Aim for 7-9 hours of quality sleep each night.
5. Gut Health: Research also suggests that our gut microbiome plays a role in cholesterol metabolism:
   • A healthy gut can increase bile acid production, which helps remove excess cholesterol from the body. 
   • When digestion slows due to constipation, bile acids (which help digest fats and are made from cholesterol) may get reabsorbed into the bloodstream instead of being excreted. This can lead to higher cholesterol levels, especially LDL cholesterol. 
   • Certain gut bacteria produce products from the food we at which can inhibit cholesterol synthesis in the liver and help reduce levels of LDL cholesterol. 

The Egg Debate: Do Eggs Really Raise Cholesterol?

For years, eggs have been at the center of the cholesterol debate. Once vilified due to their high cholesterol content, eggs have since been reevaluated in light of newer research. Here's what you need to know:

1. Dietary vs. Blood Cholesterol: The cholesterol in eggs doesn't directly translate to increased blood cholesterol levels for most people. Our bodies have a complex regulatory system that adjusts internal cholesterol production based on dietary intake.
2. Nutritional Powerhouse: Eggs are rich in nutrients, including high-quality protein, vitamins (especially B vitamins and vitamin D), minerals, and antioxidants like lutein and zeaxanthin.
3. Research Findings: Multiple studies have shown that egg consumption does not significantly impact cholesterol levels in most individuals. A 2018 study in the American Journal of Clinical Nutrition found that eating up to 12 eggs per week had no adverse effects on cardiovascular risk factors in people with pre-diabetes and type 2 diabetes.
4. Individual Responses: While most people can eat eggs without concern, some individuals may be more sensitive to dietary cholesterol. These "hyper-responders" might see a more noticeable increase in blood cholesterol levels after consuming eggs. Research suggests that approximately 25-30% of the population may fall into this category of hyper-responders. However, it's important to note that even among hyper-responders, the increase in LDL cholesterol is often accompanied by an increase in HDL (good) cholesterol, potentially neutralizing the overall impact on cardiovascular risk.

The Connection Between High Cholesterol and Insulin Resistance / Diabetes

Insulin resistance and type 2 diabetes are closely linked to dyslipidemia, a condition characterized by high levels of triglycerides, low levels of HDL cholesterol, and a predominance of small, dense LDL particles.

In insulin resistance:

1. The liver increases production of VLDL, leading to higher triglycerides and LDL levels.
2. HDL cholesterol levels decrease because the body is breaking down HDL particles more quickly.
3. LDL particles become smaller and denser, making them more atherogenic.

These changes happen even before diabetes starts, so dyslipidemia can be an early sign of insulin resistance and a risk factor for heart disease in people with diabetes.

Why Reducing Blood Glucose is the Unknown Key to Improved Cholesterol

Lowering blood sugar is key to improving cholesterol levels, but this link is often missed. Here’s why it matters:

1. High blood sugar causes inflammation that can harm blood vessels and speed up plaque buildup.
2. Too much glucose can stick to LDL particles, making them cling to artery walls more easily.
3. High blood sugar pushes the liver to make more triglycerides and VLDL, worsening cholesterol issues.
4. Better blood sugar control helps HDL cholesterol work more effectively in removing extra cholesterol from the body.

How Balancing Your Blood Sugar Improves Cholesterol Markers

Balancing blood sugar can hugely improve cholesterol levels:

1. Reduces triglycerides: Lower blood sugar means the liver produces fewer triglycerides.
2. Increases HDL: Better insulin sensitivity often leads to higher HDL levels.
3. Improves LDL size: Good glucose control helps shift LDL from small, dense (more harmful) to larger, buoyant (less harmful) forms.
4. Lowers ApoB: Better glucose metabolism decreases the production of ApoB-containing lipoproteins.
5. Reduces inflammation: Lower blood sugar levels lower overall inflammation, leading to better lipid profiles.

Natural Approaches to Cholesterol Management

Before turning to medication, consider these holistic strategies:

1. Emphasize a diet rich in fruits, vegetables, protein, and legumes
2. Incorporate fibre-rich and omega-3 rich foods like oats, nuts, and fatty fish
3. Make sure you are having regular bowel movements (1-3 per day)
4. Reduce refined sugars and processed foods
5. Balance your blood sugar - consider using a CGM monitor to confirm your blood glucose is in check.
6. Further test other markers to assess other root causes of imbalanced cholesterol, such as hormone and inflammation levels.
7. Consider supplements like those listed below (always consult a doctor as some can interact with medications)

Supplements Proven to Reduce Cholesterol

While a healthy diet and lifestyle should be the foundation of cholesterol management, certain supplements have shown promise in helping to reduce cholesterol levels. Here are some of the most well-researched options:

1. Red Yeast Rice: Contains natural compounds similar to statins, which can help lower LDL cholesterol. Studies have shown it can reduce LDL cholesterol by 15-25%.
2. Psyllium Husk: This soluble fiber can bind to cholesterol in the digestive system, helping to eliminate it. Regular use can lower LDL cholesterol by about 7%.
3. Omega-3 Fatty Acids: While they don't directly lower LDL, omega-3s can reduce triglycerides and increase HDL cholesterol. Fish oil supplements containing EPA and DHA are the most effective.
4. Niacin (Vitamin B3): In high doses, niacin can lower LDL cholesterol and triglycerides while raising HDL cholesterol. However, these doses should only be taken under medical supervision due to potential side effects.
5. Garlic: Some studies suggest that garlic supplements can modestly reduce total and LDL cholesterol levels.
6. Berberine: This compound, found in several plants, has been shown to lower total and LDL cholesterol levels.

Don’t forget that some of these may interact with prescription so please consult with your GP before starting any new supplement regimen, especially if you're already taking cholesterol-lowering medications.

Remember, there is also no out-supplementing a poor diet – food first!

What Other Bloodwork to Get Done if Your Cholesterol is High

If your cholesterol levels are high, consider requesting these additional tests for a more comprehensive assessment:

1. ApoB: As discussed, this provides a more accurate measure of your risk of heart disease.
2. hs-CRP (high-sensitivity C-reactive protein): A marker of inflammation associated with cardiovascular risk.
3. HbA1c: Measures average blood glucose over the past 2-3 months, helpful in assessing glucose control and diabetes risk.
4. Fasting insulin: Can indicate insulin resistance even before blood glucose levels become elevated.
5. Thyroid function tests (TSH, free T4): Thyroid disorders can affect cholesterol levels.
6. Liver function tests: To rule out liver diseases that can affect cholesterol metabolism.

Remember, interpreting these tests requires medical expertise, and it’s extremely helpful to get a copy of your own bloodwork too for a second opinion.

When to Seek A Nutritionist’s Guidance

Cholesterol can be a confusing topic. If you’ve made it this far, but would still like 1:1 guidance around your individual cholesterol levels and how we can improve them naturally, please click here to get in touch.

If you are interested in using a data-driven approach to balancing your blood sugar to improve your cholesterol, stay tuned for the next round of The Balance Your Blood Sugar Program coming out this month!

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‍References

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