Is Cholesterol the culprit?

By Dr Harold Gunatillake

Cholesterol – the bad fellow (LDL), and saturated fats, have been blamed since the nineteen fifties, when saturated fats were found to cause a new disease called ‘heart disease’. Ancel Keys an American researcher, in 1953 observed that those saturated fats in the diet might play a part, as a cause of coronary heart disease. Using data from seven countries, Keys compared the death rates from coronary heart disease and the amount of fats eaten in those countries to demonstrate that heart disease mortality was higher in the countries that consumed more fat than it was in those countries that consumed less.

It seems, data from many other countries were available, but Keys ignored the data from those that did not support his hypothesis. So the diet/heart hypothesis was born.

The fear for cholesterol was so conspicuous, even manufacturers of foods started labeling them “cholesterol free”, to market their products. Using animal fats, including butter, were shunned by the housewives; vegetable oils and margarine became the popular substitutes

People started going for health check ups annually to test their cholesterol levels in the blood. What is so ironical about the check ups is that most people did have the tests, but took no precautionary steps to remedy, if and when the cholesterol level was high. So with the annual health check ups, mostly paid by the companies, the tests became very popular, but the cholesterol levels among them remained high as ever. In short lifestyles did not change, but the motivation was just to go for the check ups.

Does cholesterol cause coronary heart disease? It is a minor risk indicator, says Dr Eduardo Castro,(Medical Director, Mount Rogers Clinic, VA), that has been distorted out of proportion, largely, because the cholesterol lowering drugs help decrease the incidence of adverse cardiovascular events.

The assumption is that if cholesterol-lowering drugs lead to clinical improvement, then cholesterol must be the culprit. There is increasing evidence that these ‘statin drugs’ more than helping to reduce cholesterol levels, they do act by decreasing the inflammatory processes in the inner lining of the arteries. The inflammation is preceded by cracks in the inner lining, due to turbulence of the blood flow, in addition to various other causes.

Cholesterol is a yellowish waxy water insoluble material floating in the blood stream. Being oily and water insoluble, it attaches itself to lipo-proteins making it water-soluble. Hence, the bad cholesterol is labeled as low-density lipo-protein (LDL), and the good cholesterol attached to high-density lipoproteins is called HDL.

Cholesterol is a sort of a cousin of fat. Both fat and cholesterol belong to a larger family of chemical compounds called lipids.

Cracks in the walls of the blood vessels, with surrounding inflammation attracts the floating blood cholesterol, transports to these sites, as cholesterol is needed for healing. Think of the cracks on your walls. The mason seals them with white cement. Waxy, pasty, cholesterol does exactly the same on the cracked inner lining of blood vessels. The next stage would be, the cholesterol collects at these sites in heaps, mixed with calcium, inflammatory cells, and scavenging cells from the neighbourhood. These heaped up areas are referred to as athero-matous plaques.( ‘Atheros’ means “gruel” or “porridge”).

So it appears that cholesterol is only an innocent bystander. Cholesterol is not a waste product. Over 90 percent of cholesterol is made in the liver and intestines from fatty acids and ethanol (alcohol). Cells throughout the body use cholesterol to make a number of hormones necessary for growth and reproduction. Cholesterol is a precursor molecule for oestrogen, progesterone, and testosterone. The adrenal hormones that combat stress and relieve inflammation are cholesterol dependent. When there is damage to the walls of the arteries or veins, the liver sends cholesterol through the blood to protect the tissue from hemorrhaging. Cholesterol is a component of all cell walls. They are vital to proper brain and nerve function. Low levels of cholesterol have been associated with depression, anxiety, and mood disorder. Mother’s milk is saturated with cholesterol, as it is nature’s most important component for defense and building material of the tissues of the baby.

The body has a regulatory mechanism for cholesterol, as for other endocrine systems. If one eats excess cholesterol from animal foods, eggs yolk, cheese, shellfish, and whole dairy products, the liver would produce less cholesterol from fats, and vice versa. Also, it is observed that dietetic cholesterol has no effect on the serum cholesterol.

The most influential and respected investigations of the causes of heart disease, is the Framingham Heart Study. Doctors from Harvard Medical School set up this study in the town of Framingham, Massachusetts. They measured cholesterol intake from diet and compared it with blood cholesterol. Though, subjects consumed cholesterol over a wide range, there was little or no difference in the levels of cholesterol in their blood, and thus, no relationship between the amount of cholesterol eaten and levels of blood cholesterol, was found. It was also noted that women who had the highest levels of cholesterol in their blood were ones who had eaten the least cholesterol.

After 22 years of research, the researchers concluded, “There is, in short, no suggestion of any relation between diet and the subsequent development of coronary heart disease in the study group.

The amount of cholesterol produced in the liver is about two grams a day, and the average amount eaten is about 300mg. An egg contains about 190-200mgs of cholesterol. So, without fear, one could have an egg everyday, contrary to previous beliefs.

Serum or blood cholesterol is manufactured in the liver, and intestines. Labeling as good or bad cholesterol depends onto which (low density or high density) lipoprotein the cholesterol gets attached to.

In real terms, the liver does not over-produce cholesterol. The excess, if any would be excreted as bile salts, which in turn facilitates further fat digestion and absorption of fatty acids, and cholesterol. The latter, are carried to the liver in combination with lipoproteins, as chylomicrons.

Talking about lipoproteins, or to be exact apolipoproteins, are particles of protein that are mostly formed in the liver and intestine. They play an important role in the production and transport of cholesterol around the body. There are at least nine types of apolipoprotein, including apo A-1, apo B and apo E. Each type bonds with cholesterol in the blood- either as the protective cholesterol, known as High Density Lipoproteins (HDL), or the more harmful cholesterol, Low Density Lipoproteins (LDL).

It is now observed, especially in countries like Sri Lanka, high cholesterol levels are due more to the carbohydrates we eat than fats. Carbohydrates, like rice, bread and other products from wheat flour, are broken down to sugar, glucose. Insulin is secreted to lower elevated glucose levels in the blood. Insulin is a major factor in determining how much cholesterol and triglycerides our livers produce.

If you wish to lower the cholesterol level, then limit sugar intake, as well as the carbohydrates that rapidly cause elevated blood sugar levels. Knowing the “glycaemic Index” of the carbohydrates you eat would help you to control your sugar intake.

It is well noted that we do not eat much fat per day, but it is the bulk formed by carbohydrates that are responsible for heart disease, obesity, high blood pressure, diabetes, and even arthritis.

There is more evidence that cholesterol is not the culprit. One that supports the ‘healthy’ recommendations was a Finnish trial published in 1975. In the five years trial run, cholesterol levels were lowered significantly, and the study was hailed as a success. But in December 1991 the results of a ten year follow-up to that trial found that those people who continued to follow the carefully controlled, cholesterol lowering diet were twice as likely to die of heart disease as those who didn’t- some success!

Prof Michael Oliver writing in the British Medical Journal, commenting on the results writes-
“As multiple intervention against risk factors for coronary heart disease in middle aged men at only moderate risk seems to have failed to reduce both morbidity and mortality such interventions become increasingly difficult to justify. This runs counter to the recommendations of many national and international advisory bodies, which must now take the recent findings from Finland with consideration. Not to do so may be ethically unacceptable”.

Let’s take Japan as an example. Japanese intake of animal fat has more than doubled since the end of the Second World War. Over the same period the incidence of coronary heart disease has fallen consistently.

In Israel, too an increased consumption of saturated fats was followed by a fall in coronary deaths.

Among south Asians in Britain there is an unusually high incidence of heart disease, yet living on vegetarian diets, they have low levels of blood cholesterol and eat diets that are low in saturated fats.

Until recently, Indians in India had a very low incidence of heart disease while using ghee, coconut oil, and mustard seed oil- all of which are highly saturated. The epidemic of heart disease in India began only after these were replaced with peanut, safflower, sunflower, sesame and soy bean oils, all of which are high in hydrogenated polyunsaturated oils, made into trans-fats to preserve the shelf life.

It is seen clearly, with so much trials going on in many countries, there are many doubts that cholesterol is the culprit that is related to heart disease. Atherosclerosis is definitely a specific causative factor related to heart disease. One must find the causes that lead to this thickening and blocking of vessels, rather than blaming cholesterol, including saturated fats as sure-fire sign of a future heart attack.

Cigarette smoking, High blood pressure, diabetes from any cause, lack of exercise, biochemical lesions, those that promote thrombosis, lack of certain lipoproteins, elevated levels of homo-cysteine, and many other unknown factors may be responsible for atherosclerosis –precursor of heart disease.

When studies failed to prove that lowering cholesterol made any lifesaving differences, researchers forged ahead with more multi-million dollar clinical trials. Not until statin drugs (Lipitor,Zocor,Pravachol), came along did cholesterol-lowering finally prove to be life-saving to high-risk but healthy people. Whether this benefit might actually be due to the anti-inflammatory effects of statins has been the topic of controversy ever since.

Dr Ravnskov, another researcher, is very unimpressed with the reduction in heart disease mortality shown
for the statin drugs “When you look at the CARE trial, he said, statin drug Pravachol did show a small benefit- after five years. 5.7% had died from heart disease in the untreated control group, compared to only 4.6% in the treatment group”. This researcher also believes that high cholesterol protects against cancer. It was his observation that his studies found higher rates of infectious disease among hospitalized people with low cholesterols. Also several studies found higher cancer rates in people with low cholesterol levels.

It was found women who took Pravachol in the CARE trial, 12 cases had breast cancer, compared with only one case in the untreated group.

Dr Paul Rosch, MD, a clinical professor of medicine at New York Medical College, is of opinion that half of all heart attacks occur in people with normal cholesterol levels. He further believes that stress has more deleterious effects on the heart than cholesterol.

There has been cases reported transient memory loss after statins. Duane Graveline, MD, a retired family doctor and former NASA scientist/astronaut, recounted his own hair-raising experience taking the popular statin drug Lipitor for only six weeks. Soon after he went for a walk, Dr Graveline was found wandering, confused, and reluctant to enter his own home because he didn’t recognize it or remember his wife’s name. A neurologist diagnosed his condition as ‘Transient global amnesia’.

The other side effects of statin drugs are muscle pain, weakness, fatigue, peripheral neuropathy, and rhabdomyolysis, a potential fatal muscle disease.

It is observed by many researchers that statin drug’s ability to reduce cardiovascular mortality has nothing to do with cholesterol reduction, but instead can be attributed to their anti-inflammatory effects. These drugs also deplete the body of an important anti-oxidant with muscle wasting and heart failure as a result. Co-enzyme Q10 is an important anti-oxidant formed as a bi-product in the manufacture of cholesterol. With taking statin drugs will inhibit the production of coenzyme Q10, by the liver.
Dr Peter Langsjoen MD of Tyler, Texas points out that this co-enzyme is present in traditional foods with high fat content like organ meat, seafood, and red meat. The coenzyme Q10 drops with age. Most of the Q10 research has been focused on heart failure, as the heart uses a huge amount of Q10. Q10 is available in powder form, and can be purchased from health food shops, and supplementation is advisable for those who take large strengths of statin drugs, regularly.

Lastly, one more comment- a study of elderly French women living in a nursing home showed that those with the highest cholesterol levels lived the longest (Lancet, 4/22/89). The death rate was more than five times higher for women with very low cholesterol. Several other studies have shown similar results.

The author has had many very healthy old ladies over 90 years, in his practice in Sydney, still worried about their high cholesterol levels. There you are, what more can I say!