“High” Cholesterol

Question: I have a female patient in her thirties who has been following your recommended regimen of eating mostly raw dairy (or at least non-homogenized), complex carbohydrates, bone broths, moderate amounts of various types of organic meat and organic vegetables and fruits. She avoids all processed foods and is healthy and of normal weight. However, she is concerned about her latest lipid panel, which showed a total cholesterol of 290, LDL of 200 and HDL of 79. The rest of her blood work looks all within normal limits. Hypothyroidism was ruled out but she does have a family history of hypercholesterolemia and coronary heart disease.

I have made similar observations with other patients. With the introduction of healthy unprocessed foods they are getting healthier, however, some patients’ lipid panels become more elevated while others are lowered.

While I have reviewed the research analysis in The Cholesterol Myths by Uffe Ravnskov, MD, PhD, and I agree with him that the current interpretations of lipid panels are overrated, but what should a practitioner say to his patients who are told that their cholesterol is too high? It is still unclear which mechanisms raise or lower cholesterol, particularly LDL cholesterol, and what the consequences are, if any. Unfortunately, we currently live in a world of the lowfat paradigm where patients are inundated with cholesterol-free and lowfat food choices and easy prescriptions for statin drugs. Perhaps you can offer an answer to these complex questions. –Dagmar Ehling, DOM, Durham, NC

Answer: Thank you for your very interesting question. This same issue also comes up a lot in my practice, and is probably on the minds of many of our readers. As Dr. Ehling suggests, the first step in answering this question is to read the book The Cholesterol Myths by Dr. Uffe Ravnskov. In it he describes all the recent studies on the connection between heart disease and cholesterol. His basic conclusion is that there is no connection between cholesterol, lipid levels, coronary artery disease and intake of traditional fats. Interestingly, even in orthodox medical circles one hears a lot of moaning about how “nonspecific” these numbers are in predicting coronary artery disease. What that means is that the various cholesterol levels measured in the blood do not tell us whether or not the patient is prone to heart disease. Those with low total levels of cholesterol are just as likely to have a heart attack as those with high total cholesterol.

I do, however, feel it is good to go over the lipid panels with my patients from a “conventional” point of view, mostly to show them that by assuming the numbers are relevant, we can show that, in fact, their “diet” is working. This is also the case with the patient you presented. What we are taught in the most contemporary school of lipidology is that there are four independent ways of reading these numbers, each with increasing relevance. For each marker you can divide people into “no risk,” “low risk,” “medium risk,” and “high risk.” So for total cholesterol you have the following assessment:

Total Cholesterol
No risk: less than 150
Low risk: 150 – 200
Medium risk: 200 – 250
High risk: greater than 250
Your patient’s level of 290 would put her in the “high risk” category. Please remember, though, that having a total cholesterol of less than 150 puts you in the highest risk category for cancer and early death and lots of people with cholesterol levels over 250 live long healthy lives. This is an extremely insensitive test.

The next, slightly more specific test is for total Low Density Lipoprotein or LDL, the so-called “bad” cholesterol. This type of lipid is thought to be made in your liver and to contribute to the development of coronary artery disease. Here, we have the following:

LDL Cholesterol
No risk: less than 100
Low risk: 100 -130
Medium risk: 130 – 160
High risk: greater than 160
Your patient’s level of 200 again puts her in the highest risk category. What this probably means is that her liver senses a need for a lot of this type of lipid in her system. Sometimes, this can arise from a liver imbalance or some sort of chronic oxidative stress.

The third way of evaluating lipids are the levels of High Density Lipoproteins or HDLs, the so-called good guys. These compounds are said to direct supposedly atherogenic fats away from the blood vessels and to the liver for processing. It is generally conceded that the HDLs are more specific for risk assessment than the above two values. Here we see the following:

HDL Cholesterol
No risk: greater than 75
Low risk: 60 -75
Medium risk: 40 – 60
High risk: less than 40
Here we find that your patient’s level of 79 puts her in the lowest risk category. The final and by far the most sensitive way of assessing these numbers is the ratio of total cholesterol/HDL. This gives you a sense of how much of a contribution the good HDL is to the total. This is considered the gold standard of evaluating lipid levels. Here we have the following:

Total Cholesterol / HDL
No risk: less than 3.5
Low risk: 3.5 – 4.5
Medium risk: 4.5 – 5.5
High risk: greater than 5.5
Your patient’s ratio is 290/79 or 3.7. Thus, the best test that we have for assessing your patient’s risk puts her in the low risk category even on her supposedly high-fat, atherogenic diet. In other words, your patient is fine, and, in fact, has an enviable lipid profile. I find this again and again with my patients. This dietary approach seems to put their physiology in balance, leading to true robust health.

Just a final few words on lipid levels and their “management.” The most important thing for your patient and many others is their positive protective HDL levels. It is known and has been repeatedly borne out in my personal experience that the HDL level is inversely related to the triglyceride level. For me, the triglyceride level is a key indicator because it is directly related to the amount of carbohydrates consumed as a function of exercise The more carbohydrates, of any kind, the patient consumes, the higher the triglyceride levels and the lower the HDL. So, I use lipid panels to tell me whether my patients are consuming too many carbohydrates for their activity level. If they are, the total cholesterol level will be more than double the triglycerides and the HDL will be low. I vigorously correct this by suggesting lower carbohydrate intake (yes, even grains and fruit) and encouraging more exercise or physical activity.

Finally, while I am not convinced this is related to coronary artery disease, very high LDL levels often tell me there is oxidative stress or a liver imbalance in the patient. For this condition I give 1 capsule per day of OPC synergy, a food-based antioxidant, from Standard Process and 1 teaspoon/day of an herbal bitter tonic, the best being Globe Artichoke Extract from MediHerb. This intervention will usually lower the LDL by 10-20 percent.