A thorough evaluation of your heart attack risk requires much more than cholesterol level checks. Early detection of heart disease risk is critical if you want to prevent a heart attack. In a country ravaged by heart disease, 50% of those who have heart attacks do NOT have elevated cholesterol.
Although an elevated total cholesterol is associated with an increased heart attack risk, newer tests are more predictive. A simple and inexpensive blood test for high senstivity C-reactive protein (hs-CRP) has proved to be more accurate than cholesterol screening in predicting a person’s risk for a heart attack according to researchers at the Brigham and Women’s Hospital in Boston. [NEJM, 3/23/2000]
Here are several statistics about total cholesterol:
- Among middle-aged men, 9%-12% of those men with cholesterol at 240mg/dL or greater will develop symptomatic CHD over the next 7-9 years. The problem is, however, that amongst men who do develop CHD, the majority also had one or more other risk factors that predispose them to developing CHD.
- Mortality is greatest in men over the age of 45 and specifically in those men who smoked or had elevated blood pressure along with elevated total cholesterol.
- Highest mortality occurrs in men who have total cholesterols greater than 300mg/dL.
- Women generally have about one-half the CHD risk as men for the same cholesterol levels.
- One study found that, for both men and women, CHD risk correlated greatly with level of elevation of LDL-Cholesterol and reduction of HDL-Cholesterol.
- HDL-Cholesterol is generally a better predictor of CHD. When elevated there is a lower risk of CHD, when low there is a higher risk of CHD.
Three main types of lipoproteins exist:
All three types of lipoproteins come in different sizes. HDL carries the so-called “good” cholesterol. We now know that HDL can be grouped into large and small sizes. Large HDL removes cholesterol from the arteries while small HDL does not participate in this activity. As such it could be important to know if you have large HDL, acting to protect your heart, or small HDL, not adding any protection. When measuring HDL cholesterol there is no way to know the size of HDL.LDL carries the so-called “bad” cholesterol. Unlike HDL with one good size and one bad size, all LDL is bad. LDL comes in three sizes and the smallest size is thought to be the most dangerous type. Small LDLs penetrate the artery wall easier than large LDLs and they are also more easily trapped in the artery wall where their cholesterol can be released to cause plaque build-up. When LDL becomes oxidized, it is considered to be in its most dangerous forn. Tests for oxidized LDL are just now becoming available.
VLDLs mainly carry particles called triglycerides. The VLDLs are the group most influenced by when you last ate. Large VLDL particles are the most dangerous. A combination of high numbers of both large VLDL particles and small HDL particles may place an individual at substantial increased risk for heart disease.
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Conditions that suggest Elevated Total Cholesterol
Risk factors for Elevated Total Cholesterol
(Mildly) high total cholesterol
Normal/low total cholesterol
(Past) cholesterol-lowering drug use
Elevated Total Cholesterol suggests the following may be present
The statin drugs used to treat elevated blood cholesterol levels by blocking cholesterol synthesis also block CoQ10 synthesis. Supplemental CoQ10 should be considered in anyone on statin drugs.
Elevated Total Cholesterol can lead to
It is thought that the connection between high cholesterol and Alzheimer’s disease exists in a protein called beta-amyloid, a sticky substance that builds up in the brains of Alzheimer’s patients leading to nerve cell damage and loss of cognitive function. Accumulation of the protein is believed to be related to higher cholesterol levels.
A study in Journal of Neuroimaging (July 2007) suggests that cognitively normal adults exhibiting atrophy of their temporal lobe or damage to blood vessels in the brain are more likely to develop Alzheimer’s disease. Older adults showing signs of both conditions were seven-times more likely to develop Alzheimer’s than their peers.
“Alzheimer’s disease, a highly debilitating and ultimately fatal neurological disease, is already associated with other risk factors such as poor cognitive scores, education or health conditions,” says study author Caterina Rosano. “This study, because it focused on healthy, cognitively normal adults, shows that there other risk factors we need to consider.”
MRI images of participants’ brains were examined to identify poor brain circulation, damaged blood vessels and/or atrophy of the medial temporal lobe. Subjects showing any one or a combination of these symptoms were more likely to develop Alzheimer’s in the following years.
“Similarly to heart disease, brain blood vessel damage is more likely to occur in patients with high blood pressure, high cholesterol or diabetes,” says Rosano. “Since we know that prevention of these conditions can lower risk of heart attack and stroke, it is likely that it would also lower the risk of developing Alzheimer’s.”
A study found people with total cholesterol levels between 249 and 500 milligrams were one-and-a-half times more likely to develop Alzheimer’s disease than those with cholesterol levels less than 198 milligrams. People with total cholesterol levels of 221 to 248 milligrams were more than one-and-a-quarter times more likely to develop the disease.
“We definitely cannot say that this is cause and effect,” Whitmer said. “But we know that total cholesterol levels in midlife are predictive of Alzheimer’s disease later in life. We can only say that it is a risk factor.”
It’s not possible to conclude from the study that LDL cholesterol, the “bad” kind that clogs arteries, is responsible for the relationship, she said. In the 1960s and 1970s, when data on the participants were gathered, no distinction had been made between LDL cholesterol and HDL cholesterol, the “good” kind that helps keep arteries open. [The study was presented at the American Academy of Neurology 60th Anniversary Annual Meeting in Chicago.]
Recommendations for Elevated Total Cholesterol
Taurine conjugation of bile acids has a significant effect on the solubility of cholesterol, increasing its excretion, and administration of taurine has been shown to reduce serum cholesterol levels in human subjects.
In a single-blind, placebo-controlled study, 22 healthy male volunteers, aged 18-29 years, were randomly placed in one of two groups and fed a high fat/high cholesterol diet, designed to raise serum cholesterol levels, for three weeks. The experimental group received 6 grams of taurine daily. At the end of the test period, the control group had significantly higher total cholesterol and LDL-cholesterol levels than the group receiving taurine. [Adv Exp Med Biol 1996;403:615-622]
At week 10, significant differences were observed for total cholesterol (placebo: 142.5 mg/dl vs. IGOB131: 111.9 mg/dl, p < 0.05) and LDL cholesterol (placebo: 77.7 mg/dl vs IGO131: 59.77 mg/dl, p < 0.01). Compared to baseline values, total
cholesterol decreased by 1.9% in the placebo group as opposed to 26.2% for the IGOB131 group while LDL cholesterol levels fell by 4.8% in the placebo compared to 27.3% in the IGOB131 group. Correcting for placebo values, the relative change in the total cholesterol and LDL cholesterol was observed to follow a similar pattern in the experimental group, suggesting a similar response mechanism to IGOB131 (the Irvingia Gabonensis extract) intake. [Lipids in Health and Disease 2009, 8:7doi:10.1186/1476-511X-8-]
Several studies have shown a mild lowering effect on total cholesterol and LDL cholesterol. Garlic oil does not produce this cholesterol-lowering benefit like raw, cooked or powdered garlic does. Large doses are required (6,000 to 8,000mg per day) to produce this effect, which causes gastrointestinal discomfort for some people. Furthermore, this benefit does not become evident until after 3 months of continuous use.
One month of treatment with Pycnogenol (360mg per day) reduced total and LDL-cholesterol levels, but had no effect on HDL-cholesterol levels, in a study of 40 patients with diagnosed chronic venous insufficiency. [Phytother Res 2002;16(2): pp.1-5]
Three months of using pycnogenol at 120mg per day improved erectile function and reduced total and LDL cholesterol levels in a double-blind, placebo-controlled study of 21 men with erectile dysfunction. [ Nutr Res 2003;23(9): pp.1189-98]
Choleretics typically lower cholesterol levels because they increase the excretion of cholesterol and decrease the synthesis of cholesterol in the liver. Consistent with its choleretic effect, cynara extract from artichoke leaf has been shown to lower blood cholesterol (13%) and triglyceride levels (5%) in both human and animal studies.
It is important to realize that diet is the key to lowering cholesterol levels. Restriction of processed grains, sugars and dairy, and replacing all fluids with water are key. Many doctors are finding large and relatively quick drops (as much as 100 points in several weeks) in people who follow these recommendations.
Minor cholesterol (LDL) reductions can be achieved by adding whole grains (especially oats) to the diet. This may seem confusing! Although moderate grain consumption (due to its fiber content) can lower cholesterol somewhat in some individuals, radical grain restriction may substantially lower cholesterol levels in others. If large reductions are needed or other cholesterol-lowering methods are ineffective, grain and sugar restriction may be the answer.
Avoiding carbohydrates, especially those of the high glycemic index type, can improve total, LDL and HDL cholesterol levels. The Atkin’s diet, among others, accomplishes this by avoiding them.
Soluble fiber from fruit pectin has lowered cholesterol levels in most trials. Doctors often recommend that people with elevated cholesterol eat more foods high in soluble fiber.
Cholesterol levels are much lower in vegetarians.[1-4] Vegetarian diets reduce serum cholesterol levels to a much greater degree than is achieved with the National Cholesterol Education Program Step Two diet.[5-8] In one study published in The Lancet  total cholesterol in those following a vegetarian diet for 12 months decreased by 24.3%.
Controlling cholesterol levels may be a case of not only what is eaten but how often. Men and women who eat six or more times a day have cholesterol levels that are about 5% lower than those of less frequent eaters. The researchers found lower levels of cholesterol in the frequent eaters regardless of their body mass, physical activity or whether they smoked. From other studies we know that a 5% lowering of cholesterol may be associated with a 10% reduction in coronary heart disease risk. [British Medical Journal, Dec 1, 2001]
Good fats that come from raw nuts and seeds are an important part of any cardiovascular protective diet. Pecans, for example, will lower total cholesterol, triglycerides, apolipoprotein B and lipoprotein(a). [A Monounsaturated Fatty Acid Rich Pecan Enriched Diet Favorably Alters the Serum Lipid Profile of HealthyMen and Women, Jnu 2001;131: pp.2275-2279]
Whole almonds or almond oil (replacing half of the habitual fat intake) reduced plasma triglyceride, total and LDL-cholesterol concentrations, and increased HDL-cholesterol levels in a trial of 22 men and women with normal lipid levels. [J Nutr 2002;132(4): pp.703-707]
Macadamia nuts have also been found to reduce total and LDL cholesterol, thus reducing cardiovascular disease risk. Please see the link between Increased Risk of Heart Disease and Nut and Seed Consumption.
The fiber of choice for hypercholesterolemia is psyllium, pectin or guar gum. The amount of pectin in approximately two servings of fruit rich in pectin such as pears, apples, grapefruit, and oranges is 15gm. Psyllium or guar gum are obtained by supplement. The RDA for total fiber is 20-30gm. The fiber from whole grains, especially oats does have a cholesterol lowering effect, especially in someone on a previously low fiber diet.
Three months of supplementation with ground flaxseed at 40gm per day reduced serum total cholesterol in a study of postmenopausal women. [J Clin Endocrinol Metab 2002;87(4): pp.1527-1532]
Oat bran (35-50gm per day) reduced total and LDL cholesterol levels in a controlled study of 152 overweight men with hypercholesterolemia. As one tablespoon of oat bran weighs about 6 grams, it would take roughly 6 to 8 tablespoons per day to achieve this total. [Ann Nutr Met 2003;47(6): pp.306-11]
Monounsaturated fatty acids – as contained in olive oil – reduce total and LDL cholesterol concentrations without reducing the levels of HDL cholesterol, thus leading to favorable changes in the serum lipid profile and possibly to changes in the physico-chemical properties of lipoproteins. In this way, olive oil with its high monounsaturated fatty acid content may contribute to the prevention and management of hypercholesterolaemia, a dominant risk factor for the development of atherosclerosis, and to the prevention of CHD.
A soy protein isolate reduced total and LDL-cholesterol concentrations in a study of 60 patients with high cholesterol levels. [Eur J Clin Nutr 2002;56(4): pp. 352-35]
In a study of 100 patients at the Warsaw Institute of Hematology, GHB was shown to lower cholesterol levels.
Kilmer S. McCully, M.D.
Chief, Pathology and Laboratory Medicine Service
West Roxbury Veterans Affairs Medical Center
The longest running study of cardiovascular disease in a population was initiated in Framingham, Massachusetts in 1948 and continues to this day. This important longitudinal study identified important major risks for disease, especially smoking, lack of exercise, age, male gender, and elevated cholesterol levels in younger men.
In spite of the great emphasis on cholesterol levels, the Framingham study made several critical observations that refute the “diet-heart” hypothesis. In the first place, dietary cholesterol has no relation to cholesterol levels in the blood, and dietary cholesterol has no relation to the risk of developing cardiovascular disease.
This observation was confirmed by multiple large studies from Chicago, Puerto Rico, Honolulu, Netherlands, Ireland, and the massive Lipid Research Clinics study of US citizens. The next astounding finding is that elevated cholesterol is not a risk factor for women of any age or for men over age 47.
Furthermore, both total mortality and cardiovascular mortality in Framingham participants increases in those with LOW cholesterol levels. This finding has been confirmed by multiple studies from Canada, Sweden, Russia, and New Zealand. These contradictory findings have been ignored, distorted, and incorrectly reported by supporters of the “diet-heart” hypothesis.
The massive Multiple Risk Factor Intervention Trial (MRFIT) screened 360,000 men to find those with the highest risk of developing cardiovascular disease. Approximately 12,000 overweight, hypertensive, smokers with elevated cholesterol levels were recruited for this 7 year trial, involving consuming a low fat diet, smoking cessation, exercise and anti-hypertensive drugs.
At the end of the trial, blood pressure was down, smoking decreased, and average cholesterol levels were down 7%. When the results of this $100M trial were analyzed, 115 in the treatment group had died of heart disease, compared with 124 in the control group, an insignificant difference. Looking at mortality from all causes, there were 265 deaths in the treatment group, compared with 260 in the control group. In looking at the failure of this massive and expensive $100M trial, the investigators found minor benefits of smoking cessation, no benefit of lowering blood pressure, and no effect of lowering cholesterol levels by 2% compared with the control group.
In the even more massive Lipid Research Clinics (LRC) trial, 4000 participants with very high cholesterol levels were selected from almost half a million men. After significant lowering of cholesterol levels for 7 years by the resin cholestyramine, 190 men had suffered nonfatal heart attacks in the treatment group, compared with 212 in the treated group. As for fatal heart attacks, the figures were 1.7% compared with 2.3%, a difference of 0.6%, or 12 individuals. The investigators expressed these differences as relative risk reductions of 19% and 30% by throwing out the denominators of their fractions.
In the later trials with statin drugs that lower cholesterol levels more effectively than the unpleasant resin cholestyramine, a similar statistical approach was taken to increasing the apparent effect on reducing cardiovascular mortality and adverse events.
In an analysis of 6 major statin trials (EXCEL, 4S, WOSCOPS, CARE, AFCAPS, LIPID), the reduction of cardiovascular mortality ranged from -19% to -41% when expressed as relative risk reduction, but from -0.12% to -3.5% when expressed as absolute risk reduction. This statistical manipulation to make the results more impressive illustrates Mark Twain’s aphorism: There are lies, damn lies, and statistics. Thus a multi-billion dollar drug industry depends upon using misleading interpretations of statistics showing trivial differences between treated and control groups.
The gigantic MONICA study, sponsored by the World Health Organization, analyzed the relation between cardiovascular mortality and blood cholesterol in 27 countries, in much the same way as the Seven Countries Study. The results are similar, showing that countries like Japan and China have low mortality and low cholesterol levels, and countries like Finland have high mortality and high cholesterol levels.
Yet countries like France, Germany, Switzerland, and Luxembourg have a low mortality rate and yet a high blood cholesterol value. This so-called “French paradox” is not a paradox at all, when examination of the data reveals great disparities in mortality between different regions with the same cholesterol levels.
Similarly the residents of Corfu have a 5 fold greater mortality than residents of Crete, despite identical dietary practices and identical cholesterol levels. Residents of the North Karelia regions of Finland have mortality rate of 493/100,000 and those in Fribourg France have mortality rate of 102/100,000, yet the cholesterol levels are identical at 245 mg/dl in both regions.
The National Cholesterol Education Program is a quasi-governmental body sponsored by members of the National Institutes of Health, American Heart Association, and other supporters of the “diet-heart” hypothesis. This body recommends a low fat, high carbohydrate diet to prevent heart disease, in spite of the increasing incidence of diabetes, obesity, and hypertension that is linked to consumers of this diet.
They consistently advocate programs of extreme lowering of cholesterol levels by drug therapy, in spite of evidence of increased risk of mortality from heart failure, cancer, cirrhosis, and other diseases in older subjects with low cholesterol levels. They also recently recommended lowering the acceptable level of Low Density Lipoprotein (LDL) in the population by statin therapy, in spite of the fact that 8 of the 9 members of the advisory panel had a direct conflict of interest by accepting payments from the drug industry.
This body has popularized the concept that LDL is “bad cholesterol” and HDL is “good cholesterol” in spite of the marginal and sometimes contradictory data distinguishing these fractions from total blood cholesterol. This body also advocates “aggressive cholesterol lowering” in the population in spite of the fact that no cholesterol lowering trials have demonstrated reduced mortality or sudden death from such treatments in the otherwise normal population.
Kilmer S. McCully, M.D.
Chief, Pathology and Laboratory Medicine Service
West Roxbury Veterans Affairs Medical Center
The mechanism of the cholesterol-lowering activity of phytosterols is not fully understood. Phytosterols appear to inhibit the absorption of dietary cholesterol and the reabsorption (via the enterohepatic circulation) of endogenous cholesterol from the gastrointestinal tract. Consequently, the excretion of cholesterol in the feces leads to decreased serum levels of this sterol. Phytosterols do not appear to affect the absorption of bile acids. It is believed that phytosterols displace cholesterol from bile salt micelles. Another proposed mechanism is the possible inhibition of the rate of cholesterol esterification in the intestinal mucosa.
The oral use of beta-1,3-glucan increases the effectiveness of other oral cholesterol-reducing agents, such as niacin.
A US study has shown that despite previous findings to the contrary, the nutritional supplement policosanol does not lower levels of total or low-density lipoprotein cholesterol (LDL-C).
Policosanol is derived from purified sugar cane and used in the US and other countries to treat hypercholesterolemia.
Luigi Cubeddu, from Mount Sinai Medical Center in Miami Beach, Florida, and colleagues now think that it should join the list of nutritional supplements that lack scientific evidence to support their use. “Our results are supported by a recent study conducted in The Netherlands where policosanol was found ineffective in lowering serum LDL-C in human patients.” [ Am Heart J 2006; Advance online publication]
In a recent study, the more a person exercised, the more their cholesterol improved, but positive results were seen even in those who engaged in small amounts of exercise. The amount of exercise may be more important than intensity. This means that if equal amounts of calories are spent, you would be better off with moderate exertion for longer periods than intense exertion for shorter periods of time. [NEJM November 7, 2002;347: pp.1483-1492]
Chromium picolinate supplementation at 1,000mcg per day over a 13-week period combined with exercise decreased total cholesterol, LDL cholesterol and insulin levels in a recent small study of both males and females. [J Nutr Biochem, 1998;9: pp.471-475]
There is an E-Book available called The Great Cholesterol Lie. In it, Dr. Dwight Lundell, MD, a cardiovascular and
thoracic surgeon makes it clear what causes heart disease and points out that it is not cholesterol! Click Here! to read about this book.
Probably the best form of vitamin B3 to use for the purpose of cholesterol reduction is inositol hexaniacinate (flush-free niacin). It is often given at 500mg tid for two weeks, then increased to 1,000mg tid. If using regular niacin, start out with 100mg tid working up to 1,000mg tid with meals. Niacinamide, as a supplemental vitamin, is not effective for lowering cholesterol. Niacin may also be helpful by transforming small unprotective HDL particles into larger ones which do offer a protective cardiovascular effect.
|Weak or unproven link|
|Strong or generally accepted link|
|Proven definite or direct link|
|Very strongly or absolutely counter-indicative|
|May do some good|
|Likely to help|
|May have adverse consequences|
A waxy, fat-like substance manufactured in the liver and found in all tissues, it facilitates the transport and absorption of fatty acids. In foods, only animal products contain cholesterol. An excess of cholesterol in the bloodstream can contribute to the development of atherosclerosis.
Compounds composed of hydrogen, oxygen, and nitrogen present in the body and in foods that form complex combinations of amino acids. Protein is essential for life and is used for growth and repair. Foods that supply the body with protein include animal products, grains, legumes, and vegetables. Proteins from animal sources contain the essential amino acids. Proteins are changed to amino acids in the body.
Common form of arteriosclerosis associated with the formation of atheromas which are deposits of yellow plaques containing cholesterol, lipids, and lipophages within the intima and inner media of arteries. This results in a narrowing of the arteries, which reduces the blood and oxygen flow to the heart and brain as well as to other parts of the body and can lead to a heart attack, stroke, or loss of function or gangrene of other tissues.
A disease with increased blood glucose levels due to lack or ineffectiveness of insulin. Diabetes is found in two forms; insulin-dependent diabetes (juvenile-onset) and non-insulin-dependent (adult-onset). Symptoms include increased thirst; increased urination; weight loss in spite of increased appetite; fatigue; nausea; vomiting; frequent infections including bladder, vaginal, and skin; blurred vision; impotence in men; bad breath; cessation of menses; diminished skin fullness. Other symptoms include bleeding gums; ear noise/buzzing; diarrhea; depression; confusion.
Diminished production of thyroid hormone, leading to low metabolic rate, tendency to gain weight, and sleepiness.
(mg): 1/1,000 of a gram by weight.
Molecules composed of lipids and proteins that carry fats and cholesterol through the bloodstream.
(HDL): Also known as "good" cholesterol, HDLs are large, dense, protein-fat particles that circulate in the blood picking up already used and unused cholesterol and taking them back to the liver as part of a recycling process. Higher levels of HDLs are associated with a lower risk of cardiovascular disease because the cholesterol is cleared more readily from the blood.
(LDL): Also known as "bad" cholesterol, LDLs are large, dense, protein-fat particles composed of a moderate proportion of protein and a high proportion of cholesterol. Higher levels of LDLs are associated with a greater risk of cardiovascular disease.
The main form of fat found in foods and the human body. Containing three fatty acids and one unit of glycerol, triglycerides are stored in adipose cells in the body, which, when broken down, release fatty acids into the blood. Triglycerides are fat storage molecules and are the major lipid component of the diet.
Pertaining to the heart and blood vessels.
A disease characterized by an increased blood uric acid level and sudden onset of episodes of acute arthritis.
High blood pressure. Hypertension increases the risk of heart attack, stroke, and kidney failure because it adds to the workload of the heart, causing it to enlarge and, over time, to weaken; in addition, it may damage the walls of the arteries.
Increased cholesterol level.
An essential mineral found in trace amounts in tissues of the body. Adults normally contain an average of 10 to 20mg of manganese in their bodies, most of which is contained in bone, the liver and the kidneys. Manganese is essential to several critical enzymes necessary for energy production, bone and blood formation, nerve function and protein metabolism. It is involved in the metabolism of fats and glucose, the production of cholesterol and it allows the body to use thiamine and Vitamin E. It is also involved in the building and degrading of proteins and nucleic acid, biogenic amine metabolism, which involves the transmitting of nerve impulses.
A progressive disease of the middle-aged and elderly, characterized by loss of function and death of nerve cells in several areas of the brain, leading to loss of mental functions such as memory and learning. Alzheimer's disease is the most common cause of dementia.
Magnetic Resonance Imaging. A technique used in diagnosis that combines radio waves and magnetic forces to produce detailed images of the internal structures of the body.
A sudden loss of brain function caused by a blockage or rupture of a blood vessel that supplies the brain, characterized by loss of muscular control, complete or partial loss of sensation or consciousness, dizziness, slurred speech, or other symptoms that vary with the extent and severity of the damage to the brain. The most common manifestation is some degree of paralysis, but small strokes may occur without symptoms. Usually caused by arteriosclerosis, it often results in brain damage.