Updated: Mar 1
I always find it interesting when patients tell me they don't "believe" in meds, yet they do absolutely nothing to not need them. Modern medical advances and pharmaceuticals are among the main reasons that we live longer lives while having unhealthy lifestyles. I wish modern medicine and lifestyle medicine would get married and have children, so we could bridge the gap between them, instead of seeing them in a divisive and polarized way. It doesn't always have to be one or the other. We should be fighting together towards a common goal.
I do understand wanting to take a more "natural" approach, and personally, I would rather modify my lifestyle than take meds, even if not all doctors or patients would agree. What I can't comprehend though is people choosing “natural” only when it suits them, while eating "unnatural" and highly processed food day after day, meal after meal. Have the big food corporations won? Or did we just give up?
Without meds, letting nature run its course in today's food environment would mean having drastically shorter lifespans due to chronic illnesses caused mainly by our lifestyle choices. Is that what people mean by taking a "natural" approach, because in this case, “natural” is likely going to kill you 10-15 years earlier than necessary, while making sure your last few years of existence are filled with frequent visits to my office. In the modern world, it’s next to impossible to avoid coming into contact with processed crap, but that doesn't mean you have to put it in your body.
What if I told you to choose between cholesterol medication and fried chicken? What if I told you that you could get 10 extra years of quality living, but in exchange you would have to change your lifestyle? Would you rather live healthy well into your nineties without fast food, or would you rather die next to your Big Mac in your seventies? What price would you be willing to pay to get more time with your children, your grandchildren or to make something special out the finite time you have on this Earth?
I'll always remember that patient telling me he didn't believe in my "chemicals", while holding a diet Pepsi in one hand and a pack of cigarettes in his shirt pocket. Let's call him Joe. I think all doctors have a Joe in their practice. God forbid I'd ever call Joe a hypocrite. Welcome to the profession of medicine, where hypocrisy reigns supreme.
Most people choose the fried chicken. If you're reading this post, you probably aren't one of them, or you're contemplating change. I’ve seen people who’d rather burn out young than fade away old. I’m not one of them. To me, the phrase “live like there’s no tomorrow“ is an irresponsible way to live your life, knowing that there will likely be many tomorrows and chances are that you’ll live long enough to suffer the consequences of the choices you’ve made prior. You could also choose to celebrate life's glories with other things than junk food. Everyday I see people suffer needlessly from conditions that they brought upon themselves. Don't get me wrong, many patients are just unlucky, simply victims of their circumstances. Others lack health education, but some were asking for it, unaware that chronic disease doesn't care about your beliefs or values.
The thing is, with chronic diseases, they don’t kill you quickly. They take decades. For the first 10-20 years, you can manage them, but then they really start to weigh you down. I truly believe that health is like investing in RRSP’s, or in your 401K. You invest when you’re young so you can benefit when you’re retired. The same goes for health. The time you take to invest in your health in your thirties and forties will likely determine the way you live your life in your sixties and seventies.
Now, I don’t want to make it seem like it’s your fault that you need cholesterol or other types of pills. At some point in my life, I do recognize that I too will have to take a hard look at the data and the statistics related to my personal risk. These risk calculations are also based on age, family history, blood pressure, blood glucose and blood cholesterol levels. Only when I look at the risks of taking a pill in comparison to the risks of not taking the pill will I know what to do. Emotions can always cloud our judgment, but I‘d like to think that I would rely mostly on the data, rather than personal beliefs.
One of our top killers
Heart disease is one of our greatest killers and although most people believe that genetics play an important role, studies suggest that they only account for 10-20% of overall heart attack risk. Maybe bad diets are what run in families? Did you know that there are places on Earth where people don’t die from heart disease. Imagine that! We have control over our health destiny. What a concept. Studies (aka autopsies) done on fallen soldiers, often in their twenties or thirties, have shown that cholesterol plaques had already started forming. On other parts of the planet, where plant-based diets are consumed, heart disease is unheard of. How can one of our greatest killers be non-existent in certain parts of the world?
Although I know that many of you aren’t willing to give up cheese or meat or smoking, I do know that some of you are willing to negotiate. I’m happy to inform you that plant-based benefits are dose dependent, meaning that any positive change helps. You don’t have to go all the way to see improved health outcomes.
Today, we dive deep into cholesterol. Everybody knows something about cholesterol, but most of us don't understand how to use this knowledge to our advantage. You probably already know that high cholesterol is a major risk factor for one of our greatest killers: heart disease. But did you know that elevated cholesterol is also associated with a bunch of other health conditions, like strokes, erectile dysfunction, Alzheimer's and back pain?
In this article, I'll review cholesterol and what it is. I'll explain the levels you should aim for, and how to get there with lifestyle medicine.
What is cholesterol?
Although cholesterol has a bad reputation, it's vital to support life. Cholesterol is required to build cells and your body uses it to synthesize vitamins, like vitamin D, and hormones, like testosterone or estrogen. Your liver makes all the cholesterol it needs, so it is not essential to consume it in our diets. The rest of the cholesterol circulating in our blood comes from animal products that we eat. That's right, plants do not contain dietary cholesterol. Other than dietary cholesterol, other things we eat can increase the liver's production of cholesterol. Saturated and trans fats, mostly found in animal products, will increase the production of cholesterol from our liver and I'll review this process in detail later in this article.
So if cholesterol is such a vital part of our health, why are we scared of it? Turns out that it isn't cholesterol per se that is the enemy, but rather the excessive amounts circulating in our blood vessels.
The different types of cholesterol
Cholesterol circulates in the bloodstream inside of carrier particles called lipoproteins. LDL (low density lipoprotein) is also called "bad cholesterol" because it's this type of cholesterol particle that is associated with increased risk of cardiovascular disease. HDL (high density lipoprotein) is the type of particle that transports the cholesterol for disposal and is thought to be protective. In a nutshell, you want to keep your LDL as low as possible, and your HDL as high as possible.
Why is too much cholesterol dangerous?
When cholesterol levels are low, things seem to go just fine, since our liver makes whatever our body needs. But when levels start to rise, that's when we start having problems. The amount of data linking cholesterol to vascular (blood vessel) disease is so immense that it's pretty much impossible to refute. That's why I get infuriated when I hear irresponsible recommendations from people supporting lifestyle choices that are known to increase cholesterol levels. From ''Butter is Back'' to ''Keto is King'', I've heard many claims that are fueled by profits and simply aren't evidence based. High concentrations of cholesterol coursing through your blood vessels won't give any symptoms, but over the years and behind the scenes, cholesterol circulating in your arteries is forming blockages called ''plaques'' by a process called ''atherosclerosis''.
Atherosclerosis is a pathological process where cholesterol deposits accumulate into plaques on the inner lining or wall (called endothelium) of blood vessels. Over time, the plaque can cause progressive narrowing of the artery. Once the plaque has formed, it can manifest clinically in two ways. The unstable plaque may fissure or crack, exposing and releasing chemicals within it. These chemicals are highly thrombogenic, meaning that platelets (cells that promote blood clot formation) will adhere to it and to each other and lead to an acute clot formation. If this occurs in the coronary arteries that supply the heart, we call it a heart attack. If it happens in the cerebral arteries that supply the brain, it's called a stroke. If the cholesterol plaque remains stable, meaning that it simply progressively narrows the vessel without cracking, the symptoms it will generate will be more insidious and progressive. If this stable narrowing happens in the heart, we call it stable angina. If it's in the legs, leg pain while walking will ensue. If it's in the blood vessels supplying blood to the male genitalia, it will manifest as erectile dysfunction.
Erectile dysfunction is synonymous to the saying: "the canary in the coal mine". If you have erectile dysfunction due to blockages in your penile artery or its branches, you likely already have asymptomatic atherosclerosis in other vascular beds in your body. Many studies have found atherosclerosis in arteries of teenagers and some have found evidence of cholesterol plaques in children eating processed crap as young as 10 years old. If you know someone who has had a heart attack in his forties or fifties, remember that it was the accumulation of cholesterol plugging up blood vessels over many years that likely led to to event. Please note that having atherosclerosis at age 20 is not normal, except for ultra rare genetic conditions, like familial hypercholesterolemia.
What increases it and how can we lower it?
The concentration of cholesterol circulating in your blood is directly related to your risk of atherosclerosis. The more cholesterol you have, the greater the chance of a heart attack, stroke and erectile dysfunction. Cholesterol has two main ways of appearing in your blood, either through liver production, or through diet.
Eating certain foods will increase cholesterol. Eating saturated fats, trans fats and dietary cholesterol will all increase your blood concentrations of cholesterol. Contrary to intuitive thinking, dietary cholesterol, aka cholesterol naturally found in the foods you eat, isn't the main contributor of high blood levels of cholesterol, dietary saturated fat is. For an in depth review of the different types of fats, check out my website plantbaseddrjules.com and check out the For Nerds section on Fats.
This type of dietary fat is the main contributor to increased levels of LDL cholesterol (the "bad" cholesterol). Saturated fats are mainly found in animal products and junk foods, but can be found in plants, like coconut oils and palm oils.
These fats are found in processed foods and naturally found in meat and dairy. The most inflammatory of fats, they have been banned in Canada through a phase out process that started in September 2020. Hydrogenated oils are artificially created, filled with trans fats and directly related to increases in LDL cholesterol and cardiovascular disease risk.
Cholesterol is naturally found in animal foods, mostly in egg yolk, shrimp, beef, pork and poultry, as well as cheese and butter. Counter-intuitively, it's a less potent predictor of blood cholesterol levels than the saturated and trans fats previously mentioned. People tend to assume that white meat is healthier than red meat. What people ignore is that chicken contains as much cholesterol than beef and most shellfish, like shrimps, contain even more!
Cholesterol does not exist in plant foods and although some of you maybe already knew that, corporations capitalize on uneducated consumers. Have you ever noticed how "zero cholesterol" is often plastered on many processed foods? This may lead you into thinking it's healthy, but now you know their tactics. For example, if a company would be to label their potato chips "cholesterol free", you'd now be able to reply: "Duh, plants don't have cholesterol". But that doesn't make them any healthier, since they're often cooked or fried with oils that are rich in saturated fat.
Did you notice the pattern here? Cholesterol causes atherosclerosis. Atherosclerosis progresses and causes blood vessel narrowing. Narrowing causes cardiovascular disease. The main contributors are saturated and trans fats, and to a lesser degree, dietary cholesterol. These three contributors are all mainly from animals products (meat, eggs and dairy) or from processed junk. So what happens in populations who eat mostly whole plant foods? Check out the "Blue Zones" for the answer. These are regions in the world with the highest proportion of people living past 100 years old. We've learned a lot by studying theses populations and learned that some of them don't even know what heart disease is, and that cardiovascular disease, one of our main killers, is practically non-existent in parts of the world not consuming westernized diets.
What's the ideal cholesterol target?
Decreasing your cholesterol by 1% has been shown to decrease your risk of heart disease by 2%. So you can imagine that any little improvement counts, but big improvements by any means (meds, nutrition or exercise) will yield a reduction in cardiovascular disease risk.
If you want the honest answer, it would be: the lower the better. In much the same way that studies show that your risk of cardiovascular disease is directly related to your cholesterol levels, the opposite has been shown to be true. Lower levels of LDL cholesterol are associated with a proportionately lowered risk of cardiovascular disease. Should we be putting cholesterol lowering meds in our municipal drinking water? Maybe. If they weren't linked to side effects, interactions with other medications and costs, maybe we should. Or we can just stop consuming the 3 ingredients that increase it: saturated and trans fats, as well as dietary cholesterol. Some smoke 2 packs a day and live to a hundred, while their partners die from second hand smoke at 70. Some will have heart attacks with normal cholesterol values. There are always many other factors to take into account. One of the main ones would be blood vessel lining "stickiness". I wish I could've thought of a more intellectual term, but I feel this one describes the process beautifully. For the nerds out there, the process by which blood vessels becomes sticky is called endothelial dysfunction.
Imagine cholesterol circulating in your blood vessels, much like sludge flowing in your plumbing pipes. The cholesterol can simply go about its business, not disturbing anyone while flowing freely around the vessel super highway, or it can start sticking to the blood vessel lining, where accumulation over decades leads to atherosclerosis and narrowing. Why do some people develop blockages at certain cholesterol levels while some don't? Why do some with relatively low levels of cholesterol have significant blockages? This is where the blood vessel lining's stickiness comes into play. If your artery lining is sticky, it doesn't take as much cholesterol to start sticking, accumulating and cause narrowing. If your cholesterol levels are high AND your blood vessels are sticky, then you might develop atherosclerosis faster at a significantly younger age.
What makes blood vessels sticky?
The blood vessel lining, or endothelium is far from being inactive. It produces chemical compounds that help relax and dilate the vessel, or stiffen up and contract. it produces a bunch of compounds that control adherence, or stickiness. Safe to say that the health of your endothelium is as important as the amount of cholesterol in contact with it. Many conditions are associated with "endothelial dysfunction". If you've ever watched the movie "The Game Changers", you might remember this being demonstrated by an interesting experiment, where they measured quality and quantity of erections during sleep, after having fed the participants plant-based or animals based meals. The ones who ate animal protein quickly developed endothelial dysfunction and had less penile blood flow, or erections. Although this "experiment" had many flaws (if you've read my post on research interpretation, I'm sure your can identify them), similar studies have reproduced this finding. Here are the main conditions linked to endothelial dysfunction and blood vessel "stickiness":
inflammatory diseases, like rheumatoid arthritis, lupus, Crohn's and ulcerative colitis
high intake of saturated fat, through meat, eggs and dairy
consumption of processed foods
consumption of animal protein
This basically means that if you have any or many of these conditions, your blood vessel lining, or endothelium is probably more sticky and that means that even lower levels of cholesterol might put you at an increased risk of developing atherosclerosis. Talk to your doctor about this, since the desirable levels of cholesterol that you should aim for will depend on endothelial health. We tend to have more strict cholesterol targets for patients that are at higher risk. That means that we might tolerate cholesterol levels at 4.8 mmol/L in a 20 year old male in good general health, but these levels would be unacceptably high in a 50 year old diabetic. The general rule still applies in terms of what cholesterol values to aim for: "the lower the better". As for the amount of cholesterol you should be eating, the answer would be the same. In terms of saturated fats, trans fats and dietary cholesterol, try to keep the amount in your diet as close to zero as possible. The best scientifically proven way to achieve this is through a whole food and plant-predominant eating pattern, where processed foods are minimized and animal products are decreased to as low as possible.
The other less mentioned effects of high cholesterol
We already know that cholesterol leads to atherosclerosis, which blocks arteries. What about other organs, aside from the heart and brain, where blood flow is precarious. Studies have now linked atherosclerosis to back pain, since atherosclerosis in spinal arteries can lead to decreased perfusion to cartilage, ligaments and other supportive connective tissues, where blood flow is already low. Imagine the constant wear and tear of daily life associated to decreased blood flow to weight bearing joints. These structures have a harder time healing ahead of the constant onslaught of physical trauma that far outweighs the healing power of the impaired blood flow. In vitro studies seem to suggest that breast cancer cells feed on and proliferate in a high cholesterol environment. Atherosclerosis in the brain is also associated with increased risk of Alzheimer's disease. The dangers of excess cholesterol are far reaching and usually implicated in the pathogenesis of our most common killers.
Foods that lower cholesterol
In addition to avoiding foods that increase cholesterol, like those containing saturated or trans fats, and dietary cholesterol itself, you can also choose to eat foods proven to lower cholesterol. Simply increasing your intake of soluble fiber, by any means necessary, will decrease levels of cholesterol. Remember that fiber only exists in plant foods, like fruits, veggies, nuts, seeds, legumes and whole grains. You can also consider a fiber supplement, but eating the whole food itself is clearly superior. The cholesterol lowering kings are:
oats, but all whole grains are sources of cholesterol lowering soluble fiber
beans, like chickpeas, navy beans, lentils
soy has been shown to decrease cholesterol by up to 5%
the heart healthy fats in nuts are widely known to decrease cholesterol
all other plants that have fiber and healthy fats have the potential to decrease cholesterol
Attempting To Soften The Blow
Phytosterols, like sterols and stanols, are chemical compounds that exist only in plants, mostly in nuts, seeds and oils. Their chemical structures resemble cholesterol and they can even compete with cholesterol trying to enter the body. This can limit cholesterol absorption from food. Some research suggests that sterols can also reduce the total amount of cholesterol synthesized in the body. Sterols are often added to oils or even margarine in order to soften the cholesterol blow that the saturated fat content could create. A little like sprinkling chia seeds on your chocolate glazed doughnut. Sterols do decrease LDL cholesterol by 5-15%, which is significant, but much less than the 40-50% drop we can see with statin drugs. Sterols are often added to processed foods, like margarines, dairy, breads or processed cereals. They can even be taken in pill form. Obviously, if you've been reading my blog, you might already know that I personally would recommend that you avoid or reduce foods known to raise bad cholesterol instead of sprinkling some sterols on them. For patients that already suffer from heart disease, atherosclerosis, or familial hypercholesterolemia, talk to your doctor to see if they can assist you in achieving optimal cholesterol levels.
Although sterols already exist in many plant varieties, like nuts, seeds, legumes, whole grains, fruits, veggies and vegetable oils, the average intake of these foods would equate to less than 500 mg of sterols, falling way short of the 1-2 grams per day needed to have a significant clinical effect. Phytosterol supplements, although effective, have not been thoroughly studied for long term use, or use in children. If you suffer from genetically high cholesterol, or you already have been diagnosed with high cholesterol or atherosclerosis, chances are you'll benefit from a statin drug much more than sterol supplements, but talk to your doctor if you're curious. If you're young, healthy and simply are looking to up your prevention game, maybe these supplements can help, but I'd definitely recommend cleaning up your diet first. Just like it's impossible to outrun a bad diet, it's very challenging to out-supplement a bad one. Personally, I just don't understand fortifying margarine or dairy with plant sterols. These high saturated fat containing foods are proven to increase bad cholesterol. You could simply not eat them to begin with. As a public health initiative, I do see what they're trying to do here. If you're gonna eat margarine no matter what, might as well look for the one with sterols, but recognize that labeling it as containing sterols can also be an effective marketing strategy. Make sure to check the dose or concentration, since 1000 mg or more of daily sterols are needed to lower cholesterol. The most important take home message is that adding sterols to unhealthy foods won't make them healthy, but simply less unhealthy.
Cholesterol lowering drugs
Drugs aren't the devil. Some people need them. Diet and nutrition are tools that we have to help in the prevention and treatment of disease, but they can't make you invincible. Some people, even with the perfect lifestyle, will have cholesterol values that are too high for their personal risk level. That means that maybe a combination of lifestyle modification and medical therapy will be necessary in some cases. I can't guarantee that diet and lifestyle will remove the need for medication, but I can guarantee that having a proper lifestyle will help you in taking less, or at least a lower dosage.
Although all drugs have the potential for side effects, many have helped save lives, prolong life without disability and even added years of quality and quantity of life. I prescribe cholesterol meds daily, even though I wished I prescribed them less. When I do, they're clearly indicated. I still base my decision to treat on science. For example, let's say you're a 50 year old man. If the rate of side effects of a pill is 10%, but your risk of heart attack or stroke within 10 years is 20%, would you risk it? I'm telling you that you have a 1 in 5 chance of having a life altering cardiovascular event, or a 1 in 10 chance of having a reversible side effect. You are definitely free to make whichever decision you feel is best for you, but please understand that as a responsible doctor, I'm simply basing my decision purely on statistics. The drug companies don't have me wrapped around their finger, and no they're not paying my salary. If you decide to refuse meds that I suggest you take, I will respect your decision, but I'll double check to make sure you truly understand the implications and the statistics. The rest is on you. Health is your responsibility. You have the right to choose fried chicken instead of kale. You also have the right to make poor lifestyle choices and refuse medication that tries to fix the damages you've done. I will always respect your decision, because it's yours to make and I'll still be there to do my best for you after.
I'll leave you with a final thought. Remember Joe? Although the name is fictional, the story is real. Joe made bad lifestyle choices. Joe refused the "chemicals" I suggested he take. Joe had his first stroke at 70. His wife wheeled him in the office, sitting in his wheelchair, filled with regrets. But the damage was done. Even with a bunch of pills, Joe had a second stroke. Now he couldn't even remember his children's names. Joe has since passed. He was never disrespectful, simply suspicious of "big pharma". He relied on anecdotes of friends who had side effects instead of evidence based science. Emotions guided his decisions rather than trust in healthcare professionals. He suffered a lot during the last decade of his life and although he never said it, I knew deep down that if he could turn back time, he would have made different decisions.
No matter how much we won't admit it, we are all human. We are all vulnerable to disease. Some we can't control, but most we can. Heart disease doesn't care about your beliefs and atherosclerosis will progress even if you don't believe in it. Remember that the number one killer of cardiologists is still heart disease, just like the rest of us. Mostly, remember that the main risk factors for our number one killer are all related to what we eat.
Please share with your friends, parents, or anyone who you think might benefit from reading this. If you enjoyed reading it, please let me know. Your appreciation fuels the journey I'm on to spread useful and practical information that might help make your family healthier.
Plant-based Dr Jules 🌱💚
Also go check out my recent blog post on Fat, where I also cite numerous studies describing the different types of fats. You can find it here.
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