Cholesterol – good or bad?

Cholesterol is a crucial compound in our body, making up a lot of our cell wall, many hormones and most of our brain. High levels of cholesterol (even mildly raised cholesterol) have been blamed for causing heart disease and stroke, and the pharmaceutical industry has been creating more and more powerful drugs to lower cholesterol. Is this good, or is it in fact doing us harm?

Cholesterol is a very hot topic in medicine, unfortunately vested interests and misinformation has given us a very confusing picture. If you would like to understand the background to this and the reasons for my recommendations then read the next few paragraphs (in italics) , if you want my recommendations, skip this and go down to "my thoughts on the topic."

The theory that dietary saturated fat was the principal cause of elevated serum cholesterol and heart disease comes from some research in the 1950s by an American scientist Ancel Keys. This theory was embraced by the American Heart Association.
At the same time however another scientist Johnny Yudkin argued that sugar intake was more closely related to heart disease and mortality.
Both of these were observational studies of populations, and both results were possible because most people who ate saturated fats also ate a lot of sugar. (Humans have always been carnivorous, carbohydrates became a major component of their diet 10,000 years ago, and sugar a pure carbohydrate with all the fibre and nutrition trimmed out has been part of the diet for just 300 years). The Ancel Keys 7 country study showing that those countries who ate most saturated fat have the highest levels of heart disease convinced the cardiac community and has done so ever since, even though one of his co-authors (Alessandro Menotti) later reanalysed the data and showed that the food people ate in the study that was most closely related to deaths from heart disease was not saturated fat but sugar. However the horse had bolted from the stable, and saturated fat has been targeted as the main cause ever since!

The reason for this rather confusing introduction is to show that medicine really has not made up its mind on the status of saturated fat, cholesterol and heart disease. In fact in early 2017 there was a paper written by Malhotra stating "saturated fat does not clog the arteries, coronary artery disease is a chronic inflammatory condition which can be effectively reduced by healthy lifestyle interventions", and in response to this has been a flood of papers defending the saturated fat theory.
Unfortunately big business, butter and sugar manufacturers and most importantly companies making cholesterol-lowering drugs have all stirred the pot, and it is almost impossible for doctors and laypeople to make sense of it. (Unfortunately for the sugar hypothesis, there are no companies making sugar lowering drugs, people simply have to eat less sugar, and thus the cholesterol lowering drug manufacturers have a clear advertising field.)

My thoughts on the topic

I don't think there is any doubt that coronary artery disease is due to inflammation causing cholesterol to build up the artery walls. If you have a very high cholesterol it is easier to build up, but not so for mildly high and normal levels. The major cause of inflammation is oxidation and free radicals, and this is made worse by a diet high in sugar, and obesity.
What is the best diet? – The Mediterranean diet which is high in monounsaturated fats, moderate intake of saturated fat, low in sugars is probably the healthiest. There is no doubt that trans-fats found in processed foods and high sugar are undesirable and should be avoided. Natural foods containing saturated fats such as butter cheese are much healthier and better than artificially created margarines etc.

  • Should I eat saturated fat? My answer to this is yes, but not in huge amounts.
  • What about sugar? I personally feel, along with many others that this is the major problem in the world today, and we should remove as much sugar from our diet as we possibly can, particularly in our children. Obesity leading to diabetes is going to be the Grim Reaper of our children unless we do something about it, and that is our role as parents to change. Children must be brought up to enjoy drinking pure water, not soft drinks, energy drinks and flavoured milk.
  • What about cholesterol-lowering drugs? There have been numerous studies over the years trying to reduce heart disease with diet, bile acids sequestrants (which trap the cholesterol in our gut) and many drugs. None have showed any reduction in heart disease with the single exception of the statin drugs. This does suggest that it is not cholesterol that is the major problem, and lowering it is not the way to go.
  • Statin drugs – these have become the most profitable drugs of all time, and at one stage it was suggested that everybody over the age of 50 should be taking a statin. I have written a page on statin on this website as well, but in brief statin drugs do appear to reduce the incidence of heart disease by between 15 and 25% depending on the study. Almost certainly they do this through some mechanism other than lowering cholesterol, probably as an antiinflammatory. However if you have a high risk of heart disease (previous heart attack, angina, angioplasty or bypass surgery, have demonstrated coronary disease on angiograms or CT scan, or have a very high cholesterol and/or family history of heart disease), then taking statin drugs will reduce your risk of having a heart attack or death by between 15 and 25%. These drugs do have side-effects but most can be detected, and if you are at high risk my recommendation would be to take the drugs but stopped them if significant side-effects occur.

So there we are, you're probably more confused than when you started reading this page, but welcome to the crowd.
In my opinion concerning heart disease – sugar is the major problem followed closely by trans fats, obesity, lack of exercise, refined food and not eating enough fruit and vegetables.
For primary prevention I believe reversing these is the best approach. If you have definite heart disease, I would avoid all of these and probably take a low dose of a statin drug provided it does not cause significant side-effects.