Balancing Cholesterol


“What should I do about my high cholesterol?” I was asked. I shall try to present an unbiased, evidence-based answer. I outline the main research, with linked references to look at, if you have time. I summarise what you need to know about cholesterol and its involvement in atherosclerosis, but please bear in mind that it’s not the whole story to cardiovascular disease management. I offer some private testing choices and non-pharmaceutical approaches to optimising healthy levels. If time is tight, just scan through the sub-titles to find the section you are most interested in.

The debate

You are probably aware of the mainstream medical view, the lipid hypothesis. It says that raised cholesterol is a primary cause of atherosclerosis (plaque deposits blocking the arteries) and cardiovascular disease. This originated from research by Ancel Keys and The Framingham Heart Study. A review of the history can be found here. Subsequently, there has been lot of published evidence affirming the relationship between low-density lipoprotein cholesterol (LDL-C) and cardiovascular disease. This is why doctors prescribe statins, which reduce LDL-C production by the liver.

However, some have challenged this perhaps over-simplistic view. In 2016 a meta-analysis was published in the British Medical Journal. It concluded that although there was an association (note – an “association” cannot say that it “causes” something) between total cholesterol and cardiovascular death, the risk actually decreased with age and became minimal after the age of 80. This finding is inconsistent with the lipid hypothesis (i.e. that LDL-C causes atherosclerosis).

Another turn around was in 2015, when the US dietary guidelines advisory committee reviewed all the research over the past 40 years and concluded that we should not be concerned about dietary cholesterol, arguing that it “is not a nutrient of concern”. They simultaneously lifted any previous recommendation to limit dietary cholesterol in our diets.

So, yes… the highly nutritious egg, once vilified, is now considered safe to consume.

What is cholesterol? Why do we need it?

Cholesterol is a fat molecule that’s found in every cell of the body. It is an essential part of our cell membranes, where it controls the movement of molecules into and out of the cell. It forms the chemical backbone of our adrenal hormones; sex hormones and vitamin D. Bile salts, made in the liver are also made of cholesterol. Bile salts help us emulsify (break down) fats into smaller absorbable molecules. It is said that we make approximately 75% of our own cholesterol in the liver and intestines. If dietary intake is low, our body makes more and dietary intake is high, the body makes less.

What are LDL-C and HDL-C?

Cholesterol molecules come in different shapes and sizes. They are carried in our bloodstreams by carrier proteins, because being a fat-soluble substance; cholesterol can’t mix with water in the bloodstream. The cholesterol molecules, together with their carrier proteins are called lipoproteins (meaning molecules of fat and protein). You will have heard of two (of 5) kinds of lipoproteins: low-density lipoproteins (LDL) and high-density lipoproteins (HDL). I am not going to call them “good” or “bad”, because scientists no longer think it’s that simple.

Cholesterol molecules can also be classified by their size, small and dense or large and fluffy. Some scientists believe that the small, dense LDL-C molecules are more damaging to our artery walls because they are small enough to squeeze through the artery walls and get lodged there. However, contrary to this, other doctors, like Dr. Malcolm Kendrick, argue that the LDL-C molecules are present as part of the arterial repair process, and they are not the actual cause at all. HDL cholesterol has gained interest as a more cardio protective molecule, but more research is still needed, as much is still under debate. Also, measuring molecule size has not been widely accepted in clinical practice yet.

Triglycerides and phospholipids are again molecules of fat in the bloodstream, which can either be burned for energy or stored as fat. They are often measured alongside cholesterol.

Cholesterol’s role in damaging the artery

Dr. John Campbell, cardiologist, describes the mainstream view of the cellular mechanisms of atherosclerosis in this Youtube video (48 mins).

It is believed that the body uses cholesterol like a “protective plaster” to the everyday normal chemical and physical damage that happens in the inner lining of our arteries as millions of blood cells, proteins and other molecules rush along. The body tries to repair this damage by laying down a protective layer of fat (cholesterol). This would seem like a good solution, but over time, the cholesterol can become oxidised, and this is where the trouble starts. One study reported that oxidized cholesterol was the strongest predictor of coronary artery events, compared to a conventional lipid panel test.

So, oxidised cholesterol is perceived by the body to be a foreign molecule, which needs to be removed. In response, the immune system brings in white blood cells called macrophages, to engulf or consume the oxidised cholesterol. In so doing, the macrophages become swollen cholesterol-laden “foam cells”. At this stage, we can see the fatty streaks under the microscope. Once full, the foam cells send out chemical SOS messages (cytokines) and the inflammatory response is initiated. The cytokine-mediated inflammation in the artery wall then triggers smooth muscle cells in the inner artery wall to produce collagen to help sure up the damage. This plaque gets ever bigger until it eventually ruptures, leading to the formation of a blood clot (thrombus), which can later block an artery and cause a heart attack. The diagram below illustrates this.


Formation of atherosclerosis



What determines the levels of cholesterol in our bloodstream?

The regulation of cholesterol in our body is a complex – believe me! Cell membrane receptors, enzyme feedback mechanisms and genetic factors all play a part. This heavyweight paper in 2002 states that there are over “30 genes dedicated to the synthesis and uptake of cholesterol, fatty acids, triglycerides and phospholipids”. More research is needed into how and why some of these control mechanisms may go awry.


Testing options

High cholesterol has no symptoms. Taking a cholesterol test is therefore a logical place to start. A standard lipid panel includes total cholesterol, LDL-C, HDL-C and triglycerides. From these, you can calculate your lipid ratios, which also helps to assess your risk. Please be aware that reference ranges for optimum levels vary between different published sources. Heart UK – the cholesterol charity, gives the following ranges:

  • Total Cholesterol (TC) – Ideally, 5 mmol/L or less (this is currently disputed)
  • LDL-Cholesterol (LDL-C) – ideally, 3 mmol/L or less
  • HDL-Cholesterol (HDL-C) – ideally, over 1mmol/L (men), over 1.2mmol/L (women).
  • TC:HDL ratio – TC divided by HDL-C. > 6 is considered high risk – the lower the better.
  • Triglyceride (TG) – Ideally, below 2.0 mmol/L (others say 1.7) on a fasting sample.

A straightforward home test (same as your GP would do) can now be performed with a finger prick test, Thriva’s Lifestyle test, which is £39. Alternatively, you can buy your own home self-testing kit for regular monitoring.

At the top end of the private testing market you will find Genova Diagnostics CV Health test. You might consider this test if you have a family history of heart disease, know that you have abnormal blood lipids, have obesity and/or diabetes, smoke and are physically inactive. Using state of the art technology, this comprehensive test measures a range of cardiovascular health markers (not just cholesterol). It measures the size and density of the cholesterol molecules, other important lipoproteins and inflammatory markers, homocysteine, fibrinogen and an insulin resistance score. This costs £240 and requires a full blood sample to be taken. Please don’t expect to get this on the NHS.

In addition, and particularly if you are overweight, have diabetes or metabolic syndrome you would be wise to ask your GP to test your fasting insulin level and fasting blood glucose level (normal is 4.0-5.9mmol/L), because both are indicators for heart disease.

Dietary recommendations

The National Institute for Health and Care Excellence (NICE) guidelines state that improving diet and lifestyle should be considered for primary prevention, before statin treatment commences. They also acknowledge that people may well need help in making those changes. Ask me, your Nutritional Therapist or Mother Nature’s Diet. Here are some researched suggestions:

Foods to avoid and why

  1. Avoid hydrogenated and trans fats found in most processed foods, margarine, baked goods, fried foods, sauces and salad dressings. Read here and here for more information.
  1. Avoid refined plant oils – high in omega 6 fats. I know, against all the advice we were told two decades ago. So don’t use refined vegetable oil, sunflower oil, corn oil and rapeseed oil. Omega 6 fats are linked to an increased risk of death among patients with heart disease, according to a 2013 British Medical Journal study.
  1. Avoid oxidized cholesterol. Cholesterol can be oxidized outside and inside our bodies. So it makes sense, at least, to avoid oxidized cholesterol in food. This hamster study demonstrated that oxidized cholesterol was more atherogenic than non-oxidized cholesterol. Avoid factors known to oxidise cholesterol (make it go rancid) such as commercially cooked and refrigerated meats (this means processed meats, such as smoked sausages and formed luncheon meats), deep fried foods, charring or frying at high temperatures, sunlight, microwave radiation. Keep animal foods in the dark, sealed from the air and in the fridge. Cook them gently and slowly. Don’t brown them or burn them – like they’ve been advising in the news recently.
  1. Avoid highly refined carbohydrate foods, such as biscuits, cakes, pastry, sweets, crisps etc. which raise blood sugar (hyperglycemia). When blood sugar is high, insulin will rise and in turn this causes a rise in triglycerides. The same applies to large amounts of fructose (from fruit juices) and high-fructose corn syrup in processed foods – both increase your body’s triglyceride levels, lower HDL-C and raise LDL-C. We do now know that low-carbohydrate diets (compared with low-fat diets) improve insulin resistance, HDL-C, LDL-C, particle size and particle number. Equally importantly, low-carbohydrate diets reduce inflammation.

Foods to eat and why

  1. Eat plenty of polyphenols, which have antioxidant properties. These food help to reduce cholesterol oxidation that takes place in our bodies. Some of the richest sources are cloves, dried peppermint, star anise, cocoa powder, dried oregano, celery seeds, dark chocolate (yay!), flaxseeds, elderberries, blackcurrants, chestnuts, black olives.
  1. Use coconut oil, grass-fed butter or olive oil for frying & roasting because they are high in monosaturated or saturated fats and therefore more stable at higher temperatures and less likely to oxidize.
  1. Eat mixed nuts (one handful every day) and extra virgin olive oil drizzled over salads and vegetables. Both foods help to reduce plaque formation and dilate blood vessels.
  1. Eat foods high in soluble fibre because it helps reduce cholesterol absorption from the intestine. Try oats, psyllium (a fibre supplement), flaxseeds, vegetables, apples & pears, beans & lentils, nuts & seeds. Soluble fibre also decreases systolic and diastolic blood pressure. Aim for 25-40g/day.
  1. Eat foods high in natural plant sterols (2g/day). They are found in fruit and vegetables, e.g. whole grains, legumes, nuts and seeds. Sterols have a chemical structure similar to cholesterol and therefore compete with cholesterol for intestinal absorption. Studies show their effectiveness.
  1. Eat soya based foods, containing Isoflavones, which help to reduce LDL-C. Choose traditional soya products like tempeh, miso and soy sauce or tamari. Avoid GMO soy. Choose organic, non-GMO or fermented soy. Beware, too much soy foods may not be beneficial if you have thyroid problems.
  1. Eat more Omega 3 fats Eating oily fish at least once a week can result in a 15% reduction in risk of cardiovascular disease (CVD) and a 36% reduction in CVD mortality. Try wild-caught salmon, trout, mackerel, sardines and anchovies. The NHS recognises the benefit of oily fish (around two oily–fish based meals a week can be beneficial for lowering triglycerides.

The Portfolio diet was designed by David Jenkins. Michael Moseley, of BBC fame, investigated the claims of the Portfolio diet to reduce cholesterol. The diet is a low-fat, mainly vegan (low dairy & egg) dietary approach combined with cholesterol-lowering plant foods. The results of his investigation were intriguingly mixed. In Dr Mosley’s trial, significant reductions in LDL-C were be obtained by simple dietary changes. The summary is written up nicely here. More details of the Portfolio diet can be found here. Another study supports the portfolio diet for reducing small LDL-C particle number and therefore supporting cardiovascular health.

Lifestyle recommendations

  1. Limit alcohol to one unit a day for women and two units for men, advises the current European guidelines for cardiovascular disease.
  1. Exercise regularlyStudies show consistent, regular exercise can optimise cholesterol and triglyceride levels, lower blood glucose and help maintain a healthy weight.
  2. 3. Focus on quality sleep – Quality sleep stabilises high blood sugar, which we already know lowers cholesterol. Avoid night-time snacking which raises LDL-C and our risk of obesity.


We know that there is no one single cause for high cholesterol and we know that high LDL-C isn’t the whole answer to atherosclerosis. Otherwise we would be able to explain why many people have raised blood cholesterol but don’t develop heart disease, and vice versa, why many people with coronary artery disease don’t have high blood cholesterol.

Meanwhile, what should we do if we have high cholesterol? I suggest, follow the guidelines – first start with diet and lifestyle modifications, as outlined above. Consider your genetics. Consider your diet, smoking, alcohol, exercise and sleep habits. Remember, cholesterol is only part of the story. Please also consider your blood pressure, glycemic control, weight management and fitness to reduce cardiovascular risk.

Is ageing a slippery slope?

You know what? I have been musing this subject for many years on and off. Unconsciously at first, whilst I worked on my patients bodies, now much more consciously. Here is the thought…. Here we are, bustling through life, busy, healthy, fit and well. No real health challenges to mention. Sure, a few annoying symptoms that the GP has got rid of along the way or have gone on their own… then years pass, decades pass, we have children, we get absorbed in being parents and our careers, and time flies by, then BANG! We get sick or we see our friends and family get sick. We go to the doctor and he/she tells us that we have diabetes, or heart failure or osteoporosis, arteriosclerosis, MS, depression, kidney stones, a calcified aorta, degenerative discs in our spines, endometriosis, diverticulitis, cancer, whatever.

But wait! How did that happen? How come, I was fit and well, and now all of a sudden I am told that I have some major problem? Why didn’t somebody tell me about it before I got this bad?

Aah! Now that’s the point! The very crux of the matter! It doesn’t suddenly happen. It’s happening molecule by molecule, cell by cell, organ by organ, right now, day by day, in all our bodies!

I believe we don’t listen to our bodies when they give us, what seems like, inconsequential warning signs, little by little, over the decades. We don’t want to make a fuss and we’re too busy! We don’t stop and think. There isn’t time. The pieces of the jigsaw are never quite put together for us. We can’t see the whole picture of how our body systems and mind are completely intertwined, one affecting another continuously. (But we know it’s fundamentally true). We do not make the short-term connection between what we are doing to our bodies today and the effects those actions will have 20 and 30 years down the road.


For example, we hear our rumbling stomach, pardon our burping or indigestion after a meal, excuse our wind an hour or so later, loosen our waistbands as our abdomen distends and wonder why? There’s no way we’d go to the doctor about that! Not until we get pain of course. Then we might be given painkillers or antacids or Fibrogel for “irritable bowel syndrome”. But what’s that? Well, it’s an irritable bowel of course! But why is it irritable? Well it’s like this, if somebody does something to irritate you, you get irritable. And your bowel is no different. Yes, but what’s going on inside? What happens if we don’t act? Diverticulitis? Ulcers? Ulcerative colitis? Worse?

The same insidious but progressive symptoms happen in other systems of our body. Take the spine for example. When we are young our spines get knocked about a bit! We commonly get strained facet joints and pulled muscles. Our spines adapt pretty well to this and sort of “cope”, often for a long time. Our posture adapts and compensates. We feel a few niggles, aches and pains but they go away or the physical therapist can sort it out in a few treatments. For a while. But for some poor folks, they start getting low back stiffness that doesn’t go away. Then more shrill pain comes from their joints. May be the therapist says they should come for regular treatments. But what has been going on in our spines during this time. Well, I can tell you, the discs have lost water and no longer act as shock absorbers, the facet joints have squashed up together and are rubbing and the muscles which support and move the spine, have wasted. Not good. See how the few small symptoms can progress to the degenerative spine.

One last example (but I could give you many) the cardiovascular system. Research has now shown that it is chronic inflammation in the body which causes arteriosclerosis (narrowing of our arteries). Through life, our arteries get injured due to stress, high blood pressure and irritating molecules (which we eat and drink) like trans fats, additives, alcohol, oxidants. Our body patches up those cracks with a “cholesterol scab”. This will sluff-off in time just like a scab on out skin would. However, this just repeats itself over and over if we keep irritating our artery walls with poor dietary choices and lack of exercise. Inflammation set in. The plaque building mechanism doesn’t get switched off and in time the plaques build in size and number until they eventually block the flow of blood inside the artery. Then the doctor tells us to stop drinking, when all along we’ve been told that a few glasses a night are good for you! Now we have arteriosclerosis and are at risk from stroke and heart attacks.

So what I’m saying is, if we pay closer attention along the way, (and I don’t mean neurotically) we can absolutely prevent a vast majority of “degenerative diseases” with regular screening tests and faster corrective action. Our bodies are programmed to repair, regenerate and renew our cells to ensure that we survive. Whether that “survival” feels like dragging our bodies through our 50’s, 60’s, 70’s and 80’s with a string of physical complaints or whether we glide through it, busily getting on with life, contributing to our families and communities with our hard-earned experience… it’s all down to us and our belief systems.

To follow this introduction, my next post will be all about the digestive system. It is fundamental to the optimum function of our whole body and mind. Every cell of our body is made up and functions according to what we put into our mouths every day. I will look at how it is supposed to function and what happens when it goes wrong. Why it goes wrong. I will explore the other organ system diseases we can get because our digestive system is damaged. It’s fascinating!

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