Cholesterol is not a dietary villain

The American Heart Association’s Low-Fat, Low-Cholesterol Cookbook begins with a problematic statement:

“Eating well is one of the joys of life. Because you want foods that both taste good and promote good health, this cookbook offers you lots of excellent choices ranging from appetizers to desserts, all high in flavor but low in saturated fat, trans fat, and cholesterol. These three substances — especially saturated fat — are the dietary villains that cause your blood levels of harmful low-density lipoprotein cholesterol (LDL, the “bad” cholesterol) to rise. That’s a serious concern because high cholesterol is a major risk factor for heart disease. The more LDL cholesterol circulating in your blood, the greater your risk.”

The cookbook was published a few years ago, yet it continues to linger on the AHA’s website when already in 2013 the AHA together with the American College of Cardiology issued a report that exonerated dietary cholesterol.

Only one thing is correct here, and it’s that trans fat is a dietary villain. While saturated fat does raise the cholesterol found in low density lipoprotein (LDL-C), I continue to question whether it’s truly a villain. I’ll be focusing on the facts about LDL-C and explaining why this is so.

Let’s clear up what cholesterol is and what it is not.

Whether it’s in cookbooks, papers, or online articles, the AHA seems to be the leader in calling LDL the “bad” cholesterol. This is a shame for two reasons:

  1. There is only one type of cholesterol molecule; the lipoproteins like HDL and LDL that shuttle it around the body differ. Making statements, as the AHA does on its site, that there are “two types of cholesterol” and that HDL is the “good” cholesterol and LDL is the “bad” cholesterol is misleading.
  2. LDL and the cholesterol in it are not bad. They are vital for life.

LDL delivers cholesterol to cells where it is used to produce hormones like estrogen and testosterone, used to produce bile acids that are necessary to digest fats, and used to produce vitamin D. Cholesterol is also embedded in cell membranes to serve as a crucial structural component.

When do things go wrong with LDL?

One of the statements in the opening paragraph of the AHA cookbook goes, “…high cholesterol is a major risk factor for heart disease. The more LDL cholesterol circulating in your blood, the greater your risk.”

Actually, that’s not entirely true.

By conventional standards the amount of cholesterol in the low density lipoprotein, reported as LDL-C, should be under 100 mg/dL, but what’s much more important is the number of LDL molecules, or particles, as they’re often called. The measurement taken in the NMR LipoProfile that reflects the number of LDL particles is called LDL-P.

I read a blog written by Dr. Peter Attia MD, who like myself, also mitigated his insulin resistance with dietary changes. “If you want to stop atherosclerosis, you must lower the LDL particle number. Period.” Attia writes. “LDL-C is only a good predictor of adverse cardiac events when it is concordant with LDL-P; otherwise it is a poor predictor of risk.” 

Put another way, if LDL-C is high and LDL-P is high, then there’s a problem. However, if the LDL particle number is low, then LDL-C above 100 mg/dL doesn’t necessarily mean poor cardiovascular health. LDL-P as a stronger predictor of cardiac events has been supported by many cardiology studies for years now, yet the AHA continues to emphasize lowering LDL-C when it comes to preventing cardiovascular disease.

This is why the vilification of saturated fat as the food that raises LDL-C might not be warranted. It doesn’t make sense to try and go after reducing LDL-C with statins and the restriction of saturated fats when LDL-P is what should be aggressively reduced.

Also, LDL-C can look normal while LDL-P has gone haywire. I’d like to reiterate that my LDL-C was 80 mg/dL when my insulin resistance was at its peak. Not a high LDL-C number, not a cause for alarm. It’s regrettable that I didn’t know about the NMR analysis because I suspect it would have shown a high LDL-P.

However, at that time, my triglyceride to HDL ratio was over 5 (189/37=5.11) when it should have been as close to 1 or below. Lower triglyceride to HDL ratios indicate lower numbers of LDL particles. I can infer from my ratio of 5.11 that even though the amount of cholesterol carried in the LDL was assessed as normal, it didn’t matter, atherosclerosis was a threat because the ratio indicated a high LDL-P.

We manufacture most of the cholesterol found in our bodies. We don’t absorb much of the cholesterol that we eat.

That means the cholesterol we make ourselves is the cholesterol that gets lodged in our arteries, and it gets there because small and abundant LDL particles carry it in when they embed themselves underneath the first layer of the artery wall, the endothelium.

If you don’t eat much cholesterol, then your liver is perfectly capable of making what your body needs; if you like cholesterol rich foods like eggs don’t worry about restricting your intake of them because they’re not going to do much to impact your cholesterol levels.

Following the AHA/ACC’s report, the Scientific Report of the USDA 2015 Dietary Guidelines Advisory Committee has finally concluded that dietary cholesterol is no longer a concern:

“Previously, the Dietary Guidelines for Americans recommended that cholesterol intake be limited to no more than 300 mg/day. The 2015 DGAC will not bring forward this recommendation because available evidence shows no appreciable relationship between consumption of dietary cholesterol and serum (blood) cholesterol, consistent with the AHA/ACC (American Heart Association/ American College of Cardiology) report. Cholesterol is not a nutrient of concern for overconsumption.”

To get the LDL-P number down diet does have to be addressed. Diets high in sugar and processed foods that contain sugar or rapidly break down into sugar are the instigators of weight gain, metabolic syndrome, and the production of abundant LDL particles.

Unfortunately, also following the guidelines from AHA/ACC report, the USDA calls for Americans to continue to restrict their consumption of saturated fat along with processed food and sugar. This unfairly groups saturated fat with processed food, when the scientific community has not come to a consensus on whether saturated fat is truly harmful.

If you take a look at the American Heart Association’s latest recipes for cholesterol management, some of which to be fair look quite good, it’s clear they’re still treating saturated fat as the greatest evil and for this reason some of the recipes are truly the antithesis of heart healthy cooking.

This is especially true for their breakfast options. They have a recipe for banana mini muffins that are made with white flour and sweetened with orange juice. Their oatmeal is made with fat-free vanilla yogurt that has obviously been heavily sweetened to compensate for the elimination of fat. That recipe has 17 grams of sugar per serving.

High carb foods for breakfast are the norm in America, but they elicit heavier secretions of insulin triggering, blood sugar spikes, ravenous hunger, and sugar cravings. A sensible breakfast for someone trying to combat insulin resistance and heart disease would be something like eggs with vegetables. The fat, protein, and fiber are satiating and keep blood sugar levels from spiking.

The AHA needs to streamline their information regarding cholesterol and stop confusing the public. And, if they really want to carry out their mission of building “healthier lives, free of cardiovascular diseases and stroke,” then they need to eliminate processed carbohydrates and sugar from their recipes.

The bottom line: Heavily restricting your cholesterol intake may not lower your LDL-C much at all and will not help lower LDL-P. Limiting saturated fat will not lower LDL-P. You need to cut sugar and foods that rapidly break down into it to make real improvements in your cardiovascular health.