Do We Still Care About Cholesterol?

Naturopath Dr. Robin examining a book on cholesterol.

The short answer:
Yes, but it’s more complicated than just trying to aggressively lower everyone’s numbers with medication.

Naturopath Dr. Robin standing in front of a window for a profile photo

Dr. Robin Lewis
Naturopathic Physician

In this blog, I am going to talk about some of the common misunderstandings around cholesterol. Ultimately I hope to answer the question: Do we still care about cholesterol?

With all of the advancements made in medicine, it is worth asking yourself whether or not this marker is still something worth chasing. Just because cholesterol is one of the most talked-about markers of cardiovascular disease and billions of dollars are spent every year on cholesterol-lowering drugs, doesn’t necessarily mean it’s important.

When you go in to your doctors office for your annual check-up they are often running a ‘basic lipid profile’ that contains: total cholesterol, LDL-C, HDL-C, triglycerides and your cholesterol: HDL-C ratio.

For some context, LDL-C is considered ‘bad cholesterol’ and HDL-C is considered ‘good cholesterol’. It’s when your doctor sees elevated LDL-C that you are typically put on some cholesterol-lowering therapy.

There are 4 main issues I have with this over-simplified approach

  1. These reference ranges are created from a very small sample population and therefore don’t include racial and gender diversity. Why does this matter? Unless you are a middle-aged-Caucasian man, these values may not apply to you. I have seen this issue arise many times in my non-Caucasian patients. Their cholesterol gets flagged by their other doctor and they are coming to me for a second opinion and alternative options. I then run more advanced testing and realize that they don’t have a cholesterol problem! When this happens I am still working with them to prevent heart disease and optimize their health, but the focus isn’t only on cholesterol. These are very important distinctions and ultimately lead to better preventative care.
  2. LDL-C isn’t the best way to measure the harmful cholesterol that is increasing your risk of heart disease. ApoB100 and Lpa are much better risk markers. This is because LDL-C tells you how much of this particular cholesterol there is but it tells you nothing about how many lipoproteins there are. New research has shown that the number and size of these lipoproteins is a much more accurate predictor of risk and this is what we should be measuring! ApoB100 can tell you roughly how many particles there are and this is why it is considered a better marker for ‘bad cholesterol’.
    1. What is a lipoprotein?! These are cholesterol-containing vessels that move cholesterol in your blood. Cholesterol doesn’t just float around in the blood by itself, it needs to be carried.
  3. Measuring LDL-C tells me nothing about WHY your cholesterol is high. Much to many people’s disbelief, overeating isn’t the only way we can increase our cholesterol. Cholesterol is very multi-dimensional and simply lowering it won’t necessarily correct the thing that was causing it to elevate in the first place. We call this a band-aid approach and it is one of the reasons that despite the advancements in cholesterol-lowering drugs, cardiovascular disease is still the leading cause of death worldwide.
  4. Lowering LDL-C too aggressively can be more harmful in certain populations. For example, in the elderly with memory and cognition concerns, lowering cholesterol production too much can put them at a higher risk of dementia. This is not a hard and fast rule, but should definitely be considered in anyone who’s mental capacity is declining. 

What can you do about it?

  1. Get more advanced testing, a good place to start is to ask for ApoB100 and Lpa. I would argue this is important whether or not your cholesterol has been flagged or not. This is because you can have a ‘normal’ LDL-C and an elevated ApoB100, for example. In this case, we still care about lowering that cholesterol.
  2. If your markers are coming back elevated, find a doctor who is willing to dig a little further to determine WHY. Also, keep updated on my newest blog releases for more education!

References

  1. Harper, C. R., & Jacobson, T. A. (2010, May). Using apolipoprotein B to manage dyslipidemic patients: time for a change?. In Mayo Clinic Proceedings (Vol. 85, No. 5, pp. 440-445). Elsevier.
  2. West, R., Beeri, M. S., Schmeidler, J., Hannigan, C. M., Angelo, G., Grossman, H. T., … & Silverman, J. M. (2008). Better memory functioning associated with higher total and low-density lipoprotein cholesterol levels in very elderly subjects without the apolipoprotein e4 allele. The American Journal of Geriatric Psychiatry16(9), 781-785.