Cholesterol is an issue that comes up with a fair few of my clients and it is quite interesting when you dig below the surface. Some feel it is the main driver of heart disease and must be lowered at all costs, others will say it does not matter at all and is massively overblown. There is research for both sides of the story too.
Let’s start with what even is Cholesterol? In simple terms, cholesterol is a fat-like substance that your body both makes and uses constantly. It is not just “something that blocks arteries”, it is used to build cell membranes, is a precursor for hormones such as testosterone, oestrogen and cortisol. It is also used for vitamin D and bile production.
Your doctor will measure cholesterol, or you can pay for your own test. After testing your levels, you get the total amount cholesterol, how much LDL, HDL and triglycerides.
LDL (low density lipoprotein) – often labelled “bad cholesterol” as it carries cholesterol out to tissues
HDL (high density lipoprotein) – often labelled “good cholesterol” as it helps carry cholesterol back to the liver
Total Cholesterol – This is simply the total amount of cholesterol being carried in your blood. It is made up of LDL, HDL and other particles, so on its own it does not tell you much.
Triglycerides – These are a type of fat in the blood, and in the real world they are often a reflection of your overall lifestyle. High levels are commonly linked to excess calorie intake, low activity, alcohol and poor metabolic health.
One of the problems with cholesterol debate has been the labelling of the “Good” vs “bad”, which like most things with health just leads to a oversimplified generalisation.
Typical ranges look for total cholesterol under 5 mmol/L, LDL under around 3, HDL above 1 and triglycerides under about 2.3. Doctors usually start paying more attention when LDL is consistently elevated, HDL is low and/or triglycerides are high. They also look at other risk factors such as blood pressure, smoking or diabetes. My last results were all in the normal range but I haven’t tested them for ages, so this newsletter has inspired me to get it done this week.
The Big Cholesterol Debate (Correlation vs Causation)
There has been a lot of back and forth on this debate, within the medical community and farther afield. My friend Justin Smith wrote a book called $29 Billion Reason to Lie about Cholesterol, so you can imagine where he sits on this spectrum. The two sides stem from there being a strong correlation between higher LDL levels and cardiovascular disease in the medical literature. However, not everyone with high cholesterol develops heart disease, and some people with “normal” cholesterol still do. There seems to be a huge genetic variation in how people process cholesterol. So the debate is down to whether it is correlation or causation. The condition of the artery itself, things like inflammation and damage, plays a big role in how it actually plays out in the body.
A more balanced way to look at it is that cholesterol is one factor within a bigger system, not the only cause. It is less about “cholesterol causes heart disease” and more that cholesterol interacts with damage, inflammation and lifestyle over time. So the question comes back to what causes that?
Does Food Actually Drive Cholesterol?
This is another area where advice has swung wildly over time. Historically, cholesterol in food was blamed heavily. Eggs, butter and red meat were all targeted. More recent understanding suggests that for most people, dietary cholesterol itself has limited impact on blood cholesterol levels, as the body regulates its own production quite tightly. However, some people are known as hyper responders, who are very sensitive to dietary impacts, especially saturated fat intake. This means the traditional advice works very well for them.
What seems to matter more is the bigger picture. Overall calorie balance, body fat levels, the type of fats consumed and how processed your food is. Diets high in ultra processed foods tend to worsen markers, trans-fats as well. Diets based more around whole foods tend to improve them. There is still debate here, and you will find very strong opinions both ways.
The Biggest Factors on Your Cholesterol (In The Real World)
If you zoom out from the debates and look at what actually moves cholesterol markers in real life, the main factors are fairly simple.
Smoking – This is probably the very worst thing for your cardiovascular health. It lowers HDL, increases inflammation and damages blood vessels, so cholesterol is much more likely to have a negative effect.
Exercise – The magical pill of course helps here too, it improves HDL, lowers triglycerides and improves overall heart health. You do not need extreme training, consistency in aerobic and strength exercise is what matters most, especially if you do both types of them regularly.
Weight – Body weight is a big one, higher body fat levels are strongly linked to worse cholesterol profiles, and even modest fat loss can improve markers significantly.
Food – This still matters, but not always in the way people think. In general, overeating matters more than individual foods, and diets built around whole foods tend to perform better than those based on ultra processed options.
Other factors – As with most systemic wide processes in the body, it is also affected by factors that influence your overall heath. Thus, stress, sleep, blood pressure and insulin resistance all interact with cholesterol and overall cardiovascular risk as well.
Steroids & PEDs – This is one area where cholesterol becomes very relevant. Performance enhancing drugs can increase LDL, lower HDL and increase cardiovascular risk significantly. This is one of the main health risks seen in bodybuilding and certain strength sports, especially over long periods of time. Most people who compete in bodybuilding regularly test their blood for cholesterol and liver health markers. If you see a bodybuilder taking a 2 year break from competing, it is often because they need to come off cycle to let the body recover.
What This Means For You
Cholesterol is one of the big health debates. I lean towards LDL being one factor within a wider system rather than the sole cause, but whatever your view, most people massively overcomplicate cholesterol. You do not need to obsess over individual foods or chase perfection. If you focus on the big things, not smoking, staying reasonably lean, exercising regularly, eating mostly whole foods and keeping your lifestyle in check, you will cover the majority of what actually matters. Your blood markers can be used to track these changes to see if they stand up in the real world.
If you are really worried about its effects, then you can take tests to see the quality, inflammation and damage currently within your arteries. This will give more insight into how much attention you should pay to cholesterol itself. The tests for this though are quite expensive.
Photo – Studies, books and medical tests all give their differing views on cholesterol –
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