Last week, the USDA outlined new dietary guidelines for cholesterol consumption. It has now been concluded that dietary cholesterol does not contribute substantially to total cholesterol levels. This news has actually been in the making for quite a few years, but this is the first time that the federal administration in charge of outlining dietary guidelines has conceded to the trend in studies showing that dietary cholesterol is not the villain that we once thought. They don’t quite go as far to say that saturated fats are also not evil – although most of those same studies show this to be true, as well. And they certainly don’t say that perhaps cholesterol levels themselves are over-villainized – but many studies are bringing this into question, as well. We aren’t likely to see a complete change in cholesterol treatment in the near future, but, could this be at least the beginning of the demise for the anti-cholesterol regime that has reigned for so long? Let’s examine it further.
The change in recommendations primarily stems from a meta-analysis published last year in the Annals of Internal Medicine, which combined results from more than 70 studies that included a few hundred thousand people. It found that those who consume higher amounts of cholesterol and saturated fat have no more heart disease than those who consume less. Again, this is a large compilation of nearly 80 independent studies.
This is quite a turn-around considering that cholesterol has been feared for decades…literally. Warnings against consumption began in the 1960s. But studies along the way are innately complicated by combinations of types of fats and the varieties of foods that contain fats and attempting to separate these (or not) for study. A good example is trans-fats versus naturally occurring fats including saturated fats. Man-made trans-fats found in margarine, shortenings, and many processed foods and bakery items have independently been linked to disease, but these fats tended to not be separated out in study from naturally occurring saturated fats until relatively recently. Another caveat to consider is that animal products, which are high in saturated fat, are also higher in an essential fatty acid called arachidonic acid, which has been shown to increase inflammation if consumed in too high of an amount. Inflammation itself is strongly implicated in heart disease. So are links between saturated fats and heart disease due to cholesterol or due to inflammatory products that are in some, but not all, types of saturated fats? To my knowledge this has not been controlled for in study, but would explain why saturated fats in coconut oils, nuts, dark chocolate, and other “healthy” fats tend to show a decrease in cardiovascular disease rather than an increase even though they too are saturated. To further this point, consider that the health-promoting Mediterranean diet has about 45 percent of calories from fat, including moderate amounts of meat, so it has never really fit into our “limit fat” mantra, but it tends to show the best results in decreasing cardiovascular disease.
This is not to say that cholesterol is not involved in heart disease, we probably have just been looking at it incorrectly, and giving it too much credit for causation. In fact, it is now thought that the ratio of HDL (“good” cholesterol) to LDL (“bad” cholesterol) is more important than the total cholesterol. Cholesterol and saturated fats such as those in eggs have actually been shown to increase HDL, decrease triglycerides, and improve cardiovascular health, so it seems that all this time when we limited dietary cholesterol, we were actually doing ourselves a disservice. In 2012 a large study of more than 50,000 women concluded that women with “high” cholesterol greater than 270 mg/dl had a 28 percent lower mortality risk than women with “low” cholesterol, less than 183 mg/dl. Researchers postulated that, if you’re a woman, your risk for heart disease, myocardial infarction, and stroke are higher with lower cholesterol levels. There also seems to be a relationship with the size of LDL particles, which can be small and troublesome, or larger and less causative of disease. We can test for these using a test called NMR in addition to a cholesterol panel, but they are harder to control with treatment. Understanding how to control particle size might very well be the cholesterol treatment of the future.
What we need to remember, but we so often lose track of, is that cholesterol is a naturally occurring product of our liver, but one that we can also ingest in our food. As it became our “enemy,” we lost sight of the fact that it has important functions in the body. Cholesterol is the primary backbone for hormone production and there are interesting studies linking hormone deficiencies such as hypothyroid and low testosterone with elevating cholesterol levels (perhaps the body’s attempt to make more of a fledgling hormone?). Cholesterol is also an important component of structure and communication in the cell membrane. Having low cholesterol can affect brain health, and commonly prescribed statin medications to lower cholesterol now carry a bottle label warning for dementia. Again, I’m not recommending that all treatment should be abandoned, but conversations should be had between yourself and your treating physician to set reasonable goals for your cholesterol treatment.
Other precautions should be to limit what seems to be the more predominant causative factor in cardiovascular disease: inflammation. We know that waxes and wanes in our blood sugar levels can contribute significantly to inflammation, which nutritionally implicates carbohydrates as more troublesome than fats when it comes to heart disease. Certainly simple sugars should be moderated. As stated above, animal products are also more inflammatory than other sources of fats. Red meats are more inflammatory than other meats and should still be limited to 2-3 times per week. Dairy should be limited to 1-2 servings per day. Completely remove trans-fats, which are often listed on labels as partially hydrogenated oils. Do eat sources of fat including avocados, olive oils, olives, lean meats, nuts, and coconut oil. Increase vegetables in your diet, which, let’s face it, never get implicated in studies to be bad for us. Eat 2-3 servings of fruit. Limit processed foods and shop the periphery of the store.
At this point, the standard of care has only adjusted to allow cholesterol and some saturated fats back into the national dietary guidelines. As an educated advocate for your own health, however, you should be educated in the knowledge that cholesterol implications, monitoring, and treatment are currently debated issues, with standards of care for treatments likely to change in the coming years. Continue to check in with your treating physician for changes, but in the meantime, at least enjoy those eggs.
Stay healthy & be well!
– Amy Whittington, NMD