Author: Dr. Bonnie Brock, NMD, RD, MPH
Cholesterol is a waxy substance found throughout the body and is needed to build cells, vitamins and hormones. Cholesterol comes from two sources. Your liver typically makes all the cholesterol you need. You can also obtain cholesterol from your diet by eating animal-derived foods like meat, poultry and dairy. You do not obtain cholesterol directly from plant-foods because plants do not have their own livers to make their own cholesterol. That being said, heavily processed plant-foods like hydrogenated oils, tropical oils, refined carbohydrates, trans-fats and sugar syrups can raise your cholesterol in an indirect way.
Cholesterol is transported to and from cells by lipoproteins, a sort of “fat transporter” in the blood. LDL (sometimes called “bad cholesterol) is the lipoprotein that carries fat from the liver to the tissues. High LDL over time raises your risk for heart disease and stroke as it indicates that fat is collecting on the walls of the blood vessels. HDL (sometimes called “good cholesterol”) on the other hand, carries cholesterol away from the peripheral tissues and back to the liver to be processed. A healthy HDL level may indicate a lower risk for heart disease and stroke. Elevated levels of another lipoprotein, called apolipoprotein B, is associated with an increased risk for atherosclerosis (plaque build-up in the arteries), which, when left untreated, increases the risk of heart disease. Triglycerides are the way in which dietary fat is present in the blood and can be picked up from the GI tract after meals and also made by the liver. Elevated fasting triglycerides can indicate blood sugar dysregulation, insulin resistance, fatty liver, adrenal dysfunction and/or cardiovascular disease. It is important for everyone to know and understand their blood lipid levels in order to assess their risk of a cardiovascular event. A routine lipid panel will measure total cholesterol, HDL, LDL and triglycerides. An advanced lipid panel has been developed by Cleveland Heart Lab and measures additional lipoproteins and other cardiac inflammatory markers.
Some people are genetically predisposed to having much higher than “normal” cholesterol and lipoprotein levels. These genes can be inherited from their mother, father or both parents and this condition is called familial hypercholesterolemia. Familial hypercholesterolemia(FH) is an inherited defect in how the body recycles LDL (bad) cholesterol. As a result, LDL levels in the blood remain exorbitantly high. People with FH are born with already high LDL levels and without treatment, they may be at risk for early heart disease. FH may also present with elevated lipoprotein a (Lp(a)) levels, which is another independent risk factor for heart disease.
I am frequently asked by patients with FH if a statin medication is the only option to reduce cholesterol and mitigate cardiovascular risk. Statins are a class of drugs that inhibit the enzyme hydroxymethylglutaryl-coenzyme A (HMG-CoA) reductase, which is a key step in cholesterol synthesis. By blocking this enzyme, statins reduce the production of cholesterol in the liver. While several studies do show that risk of coronary event is reduced to that of people with non-genetic high cholesterol, I believe managing FH is multi-faceted and there are several things to consider before a statin is prescribed. Of course, all patients with high lipid levels should maintain normal weight, eat a heart-healthy diet, not smoke cigarettes and exercise regularly. In addition, the American Heart Association recommends having a coronary artery calcium test when risk status for people 40 to 75 years old is uncertain to determine who will benefit from statins. Also known as a CAC test, this non-invasive type of rapid X-ray called a CT scan takes cross-sectional images of the vessels that supply blood to the heart muscle, to check for the buildup of calcified plaque. Plaque is composed of fats, cholesterol, calcium and other substances in the blood and its presence in the arteries is typically what causes a heart attack. The measurement can help a doctor identify who is at risk for heart disease before a person has signs or symptoms. “A coronary artery calcium score can help refine decision-making about whether someone needs medication to reduce their risk,” said Dr. Donald Lloyd-Jones, a cardiologist and chair of the Department of Preventive Medicine at Northwestern University in Chicago. As a Registered Dietitian and Naturopathic Medical Doctor who has been treating high cholesterol for several decades, I have seen great variability between a patient’s cholesterol level and the calcium score. My typical recommendation before prescribing a statin for any case of high cholesterol is checking in on good lifestyle habits, understanding the individual’s risk factors for a coronary event and ordering a coronary artery calcium test.
