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27th October, 2021


Wellness

Cholesterol Awareness Month

We have known for decades that there are associations between levels of high LDL cholesterol (so called “bad cholesterol”), deposits of cholesterol in artery walls, and heart disease, but there have been inconsistencies which have raised some questions and concerns about the original simple theory that cholesterol causes “furring” and blocking of blood vessels which then results in a heart attack. 


It is now well established that damage to the arteries of the heart is not just based on clogging and narrowing by cholesterol. Heart disease is actually a condition of chronic inflammation. 


There always were discrepancies in the original cholesterol theory.


For example, although a high intake of saturated fats often found in meat and dairy products has been blamed for high circulating LDL cholesterol, not all saturated fats are created equal and some saturated fats actually have little or no effect on cholesterol levels. Transfats, largely found in industrialised processed foods and recently banned in many parts of the world certainly increase the amount of harmful LDL cholesterol but are also “proinflammatory”, promoting inflammation which is now known to be a key driver of heart disease. Meanwhile unsaturated fats such as those found in foods such as nuts, avocados and olive oil for example tend to reduce levels of LDL cholesterol but also have anti-inflammatory effects, which may be considerably more important. Other ingredients may affect absorption or metabolism of cholesterol in a beneficial way such as oats and plants rich in fiber, but it is the relationship between cholesterol and inflammation which is of most interest.


Diet is very important in preventing heart disease. The dietary pattern with the most evidence demonstrating a protective effect is the Mediterranean Diet which can reduce the relative risk of heart disease by thirty percent. However, it has been demonstrated on many occasions (with a few exceptions) that dietary changes have relatively little impact on LDL cholesterol levels - perhaps between 5 and 10 percent in most real world studies. It seems that even when people try their hardest, there are limits to their capacity to reduce cholesterol levels. 


There are some interesting conclusions we can draw from this - firstly that despite the powerful effect of diet, most algorithms used by doctors to assess risk ignore the quality of a person’s diet and focus entirely on more easily measured risk factors such as cholesterol levels, blood pressure and age. It would appear there is rather limited scope to reduce those risk factors though lifestyle changes. This makes these tools rather limited because factors such as a diet with plenty of anti-inflammatory foods, and the amount we exercise, are simply not on the scoresheet. This means that if someone is “in the statin zone” based on the results of the calculation, they are unlikely to escape from this, even if they improve their lifestyle substantially. They are unlikely to have a big impact on cholesterol levels and sadly, even less chance of altering their age to become younger! Two people might have very similar numbers on the risk measurement yet we know that if one of them has a much healthier diet and exercises a lot, their risks must surely be significantly lower than the other even though this may not be the outcome of the risk tool. The old adage applies that the information we get out is only as good as the information we put in.


Furthermore, if there is such a mismatch between the substantial effect of diet on the risk of heart disease and yet its apparently low capacity to change cholesterol levels, there must be something else going on. 


This brings us back to the role of inflammation. 


There is increasing evidence that LDL cholesterol is much more damaging when it has deen destabilised by reactive chemicals called free radicals. The reaction is called oxidation. The LDL cholesterol becomes oxidised, and in an environment of excess free radicals described as “oxidative stress”, the instability of this oxidised LDL cholesterol can cause inflammation and the disruption of blood vessels and the formation of dangerous blood clots leading to a heart attack. 


It is interesting to note that several drugs given to patients with heart disease have antioxidant activity including aspirin, ACE inhibitors and statins, and at least part of the way they work may be down to their ability to reduce oxidation of cholesterol and thereby reduce inflammation set up by the chain reaction of this harmful chemistry.
A diet rich in naturally occurring plant antioxidants, present in abundance in diets such as the Mediterranean Diet with its variety of colourful vegetables and fruit, has been shown to reduce oxidative stress and the risk of heart disease, as well as many other chronic diseases which are driven by a state of chronic inflammation. 


Extra virgin olive oil - the ubiquitous ingredient central to the Mediterranean Diet illustrates very well the relative importance of fat and antioxidants. Olive oil contains an abundance of monounsaturated fat, with some polyunsaturated fats and a small proportion of saturated fats. It is regarded as being a healthy oil to use for cooking and preparing all dishes, just as they do in the Mediterranean. It should have a beneficial effect on cholesterol levels. However, it is the anti-inflammatory, antioxidant constituents called polyphenols in unprocessed extra virgin olive oil which have been shown to protect LDL cholesterol from harmful oxidation and which is likely to play an even more important part in its well documented heart healthy effects. Particular polyphenols have been shown to have a dramatic effect on reducing oxidised LDL, and extra virgin olive oils with a particular minimum levels of some of these polyphenols are permitted to carry an authorised European Health Claim for their beneficial effects. 


Although a cholesterol result will not give an indication of the level of oxidized cholesterol, we can all make changes to our diets to ensure we maximise the natural antioxidants in foods by adopting a Mediterranean pattern of eating - with vegetables cooked and prepared with extra virgin olive oil, fruits, whole grains, pulses, herbs and spices. These will all provide plenty of antioxidant plant compounds such as  polyphenols and carotenoids which may well play a part in reducing harmful oxidised LDL cholesterol. We can often see them in the colours and the pleasant spicy, peppery and bitter flavours of many of these foods. 


It is good to be aware of cholesterol, but perhaps even more important to be aware of, and enjoy, those healthy foods which can reduce oxidative stress and inflammation of cholesterol and thereby protect us most.

 

Dr Simon Poole MBBS DRCOG
Cambridge, UK
+44(0)7977264016

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