Why cholesterol may not be as important as you might think when it comes to lowering risk of heart disease
Trying to prevent heart disease by lowering cholesterol is like trying to prevent obesity by cutting out lettuce. Surprised? Read on.
Last year, cardiologist Stephen Sinatra and I came together to write a book—The Great Cholesterol Myth—which will be out later this year. We believe that a mix of misinformation, scientifically questionable studies, corporate greed, and deceptive marketing has conspired to create one of the most indestructible and damaging myths in medical history: that cholesterol causes heart disease.
The real tragedy is that by putting all our attention on cholesterol, we’ve virtually ignored the real causes of heart disease: inflammation, oxidative damage, stress, and sugar. Things we can actually do something about using food, supplements, and lifestyle changes, none of which have the costs—nor the side effects—of drugs.
Now, to explain how this myth got started—and why it endures, despite a ton of evidence showing that it’s about as accurate a theory as “the world is flat”—would take many more pages than I have in this column. (If you’re interested, I hope you’ll read the book.) Instead, I’m going to lay out the highlights of the case against the cholesterol hypothesis. I’m also going to tell you what you can do to keep your heart healthy and to lower your risk of cardiovascular disease.
First, let’s start with some surprising facts.
- Cholesterol is a minor player in heart disease
- Cholesterol levels are a poor predictor of heart attacks
- Half of heart attacks happen to people with normal cholesterol
- Half the people with elevated cholesterol have healthy hearts
- Lowering cholesterol has an extremely limited benefit
I haven’t come to these conclusions lightly, and I wouldn’t expect you to take them at face value. The case against cholesterol as a cause of heart disease (or even as an important marker for it) has been crumbling steadily for decades, but getting the information out there is difficult. (The two top cholesterol-lowering medications, Lipitor and Zocor, together bring in roughly 34 billion dollars a year for their makers, who have a strong vested interest in keeping the cholesterol theory alive. And they’re hardly the only ones who do.)
But if you’re willing to consider breaking with conventional thinking for a minute, consider the following three studies.
The Lyon Heart Study
In the 1990s, French researchers decided to run an experiment, known as the Lyon Diet-Heart Study, to test the effect of different diets on heart disease.
They took two groups of men who had every risk factor for heart disease imaginable. All of them had survived a heart attack. They had high cholesterol, they smoked, they didn’t exercise, and they had high levels of stress. Half the men were advised to eat the American Heart Association “prudent diet” (low saturated fat and cholesterol), while the other half were advised to eat a Mediterranean diet high in fish, omega-3s, vegetables, and monounsaturated fats like olive oil.
The study was stopped midway because the reduction in heart attacks in the Mediterranean group was so pronounced—70%!—that researchers decided it was unethical to continue.
So what do you think happened to the cholesterol levels in the men who ate the Mediterranean diet and had 70% reduction in deaths? You’d think they must have dropped like a rock, right?
Think again. Their cholesterol levels didn’t budge, and were just as high when the study was stopped as they were when it began. The men just stopped dying. Cholesterol had nothing to do with it.
The ENHANCE trial
A 2008 study tested a combination cholesterol-lowering medication called Vytorin. The new wonder drug lowered cholesterol just fine. In fact, it lowered it better than a standard statin medication (the gold standard of treatment for cholesterol lowering). Only problem was, the people taking Vytorin actually had more plaque growth than the people taking the standard medication. The patients on Vytorin actually had almost twice as great an increase in the thickness of their arterial walls, a result you definitely don’t want to see if you’re trying to prevent heart disease.
So to sum up this study, everyone taking the cholesterol-lowering “wonder” drug saw their cholesterol go down and their risk for heart disease go up.
The Nurses Health Study
The Nurses Health Study is one of the longest-running studies of diet and disease ever undertaken. In an exhaustive analysis of 84,129 of these women, published in the New England Journal of Medicine, five factors were identified that significantly lowered the risk for heart disease. In fact, wrote the authors, “Eighty-two percent of coronary events in the study …. could be attributed to lack of adherence to (these five factors).”
Are you ready for the five factors?
- Don’t smoke
- Drink alcohol in moderation
- Engage in moderate-to-vigorous exercise for at least a half hour a day on average
- Maintain a healthy weight (BMI under 25)
- Eat a wholesome, low-glycemic (low-sugar) diet with plenty of omega-3 fats and fiber.
Wait, didn’t they miss something? Where’s the part about lowering cholesterol? Oh. It’s not there. Never mind.
These studies are just a sample of the evidence against cholesterol as the cause of heart disease. The Framingham Heart Study, which began in 1948 and is still going on, actually shows clearly that
high cholesterol is protective in older adults—those in the study who lived the longest tended to be those in the “highest cholesterol” category. And let’s not forget that cholesterol is the parent molecule for the sex hormones and vitamin D. It’s also vitally important in the brain, where it lives in places in the cell (the lipid raft) that makes communication between cells easier.
So if cholesterol isn’t the cause of heart disease, what is? Here’s the short answer: The primary cause of heart disease is inflammation. Small injuries to the vascular wall that can be caused by anything from high blood pressure to toxins that cause oxidized (damaged) LDL particles to take up residence in the area; the immune system sends inflammatory cytokines to the area, eventually resulting in plaque and an increased risk for heart disease. If there was no inflammation, the arteries would be clear.
The following is my seven point program for reducing the risk of heart disease. Note that lowering cholesterol isn’t on it. Pay attention to these seven action items, and you just may find that you don’t need to worry quite so much about cholesterol after all.
Eat an anti-inflammatory diet. The plant kingdom is just loaded with natural anti-inflammatories (and antioxidants for that matter). Berries, apples, onions, and cherries are outstanding examples, but far from the only ones. Wild salmon contains anti-inflammatory omega-3s as well as astaxanthin, a powerful antioxidant. And put green tea, pomegranate juice, and dark chocolate in heavy rotation on your menu
Reduce grains, starches, sugar, and omega-6s. For many people, grains—particularly wheat—can be inflammatory. Sugar contributes to heart disease by creating damaging toxic molecules known as AGEs (advanced glycolated end-products) that contribute to inflammation in the artery walls. And omega-6 fats—while necessary—are pro-inflammatory, and we consume far too much of them. Refined vegetable oils (like soybean and corn oil) are loaded with omega-6s. Switch to olive oil, macademia oil, and coconut oil for cooking, and be sure to balance your intake with fish oil and flaxseed oil.
Supplement with antioxidants, vitamin C, Coenzyme Q10, omega-3s. Omega-3s are among the most anti-inflammatory substances on the planet and should be part of everyone’s heart-healthy supplement program. Ditto with antioxidants, like vitamin C. And CoQ10 is fuel for the heart. (It’s also depleted by cholesterol-lowering medications, so if you’re on one of those you simply must supplement with CoQ10 on a daily basis!)
Manage your stress. Stress is a powerful contributor to heart disease. The stress hormones create inflammatory events that may explain why 40% of atherosclerotic patients have no other risk factors. They also raise blood pressure, which in turn contributes to vascular injury. Doing damage control on stress levels is a critical part of your anti-heart disease program. Whether in the form of meditation, deep breathing for a few minutes several times a day, or a warm bath with candles, find some time for yourself and relax. Your heart will thank you for it.
Exercise. There’s probably no better thing you can do for your heart (and brain)! Even brisk walking for 30-45 minutes, 5-7 days a week can considerably reduce your risk for heart disease.
Drink only in moderation. Yes, alcohol has been shown to be somewhat cardioprotective, but, as they say, moderation is key. If “moderation” is something you can really do, then one drink a day for women and two a day for men is fine (with red wine being especially recommended). If it’s not, don’t start.
Don’t smoke. This one seems obvious, yet it’s impossible to overstate how important it is. If you want to reduce your risk of dying from heart disease—not to mention cancer—throw out your cigarettes. Just do it.
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