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Cholesterol is not just cholesterol. For many years, we've been told that high cholesterol can lead to cardiovascular disease, and eggs, steak and other foods have been singled out as the major culprits in the fight against cholesterol. But is that really the case? We asked doctor and health advisor Pia Norup to give us a lesson in the world of cholesterol.
What is cholesterol?
Cholesterol is a very important fat that occurs naturally in the body and has two main functions:
The vast majority of the body's cholesterol is formed in the liver. We also get cholesterol from our diet, but new research casts doubt on the commonly held beliefs about what in the diet raises cholesterol levels. It turns out that the dangerous things in the diet are more likely to be sugar and simple carbohydrates than fats - if the fats are the healthy kind (see our article on fat here).
Cholesterol and cardiovascular disease
A risk marker (or simply marker) for a given disease is a kind of warning that a disease may occur due to this or that. A good risk marker has a very high correlation with the disease and is good at both catching those who are at risk of developing the disease and "exonerating" those who are unlikely to get sick. Elevated blood cholesterol is a marker of disease. This means that there is a correlation between high cholesterol and the incidence of cardiovascular disease.
Cholesterol concentration is measured as standard, as it is considered a good risk marker for cardiovascular disease. Cholesterol can accumulate in the vessel wall (arteries and blood vessels) and turn into fatty deposits, causing vessel thickening and eventually causing narrowing and ultimately blood clots.
But is cholesterol a good marker for cardiovascular disease? The answer is that cholesterol is not a very accurate marker. There are far more accurate and powerful markers and conditions that we don't normally measure as standard. However, we do at Capio CFR in the form of the Comprehensive Cardiovascular Risk Profile (True Health), where we look at a wide range of risk markers for cardiovascular disease. More on this below - first, let's take a closer look at cholesterol.
There is a difference between cholesterol
Cholesterol is typically measured as the concentration of total cholesterol in the blood as well as the concentration of the subgroups of cholesterol, LDL (Low Density Lipoproteins) and HDL (High Density Lipoproteins). There is also VLDL (Very Low Density Lipoproteins).
LDL and VLDL are the 'harmful' cholesterols. They are known to be so-called atherogenic markers - risk factors that can cause atherosclerosis. LDL is the main culprit, so we will focus on this one first.
Small and dangerous or big and harmless?
Simply measuring the total concentration of cholesterol is not always sufficient to assess the risk of cardiovascular disease. It can be important to measure the number and size of molecules and particle concentration, which is not measured in a standard blood test in the UK. The same concentration of cholesterol can cover many small, dangerous molecules or fewer large, harmless molecules.
LDL molecules can be either large and fluffy or small and very compact (small dense). The 'small dense' LDL molecules (sdLDL) are the dangerous cholesterol molecules that easily penetrate the vessel wall and cause fat deposition and eventually inflammation, i.e. inflammation of the vessels (without bacteria), which is an important part of the mechanism of blood clots. Small LDL molecules (sdLDL) are most commonly seen in people with diabetes or pre-diabetes and possibly metabolic syndrome, which is a disorder in the body's metabolism of nutrients, leading to insulin resistance, high blood pressure and high cholesterol.
You can measure both the number of particles and the concentration of cholesterol in the particles.
LDL particle number is a much stronger marker of disease than LDL concentration. If the particle count is elevated, it is a risk, even if the overall LDL concentration is normal. However, a standard blood test in this case will only tell you that the LDL cholesterol concentration is normal - a normal LDL cholesterol level.
Other markers for cardiovascular disease
There are many other markers that predict the risk of fat deposition in the vessels and thus the formation of atherosclerosis and blood clots.
Genetic predisposition
There is a genetic predisposition to cardiovascular disease that can be measured by the ApoE (Apolipoprotein E) genotype. People who have a specific genetic coding for ApoE have a significantly higher risk of cardiovascular disease and it is often very common in these families.
Individuals with this genetic coding are more resistant to both medical treatment and lifestyle modification, but need both interventions. These individuals are much less able to tolerate fats than others, even if they are healthy fats. A cure for people with this genetic coding for ApoE is therefore a very low-fat diet.
Medicine and diet
Cholesterol-lowering drugs, statins, can reduce the number and concentration of cholesterol molecules, but do not affect the size distribution of cholesterol molecules. In other words, there can be an equally skewed distribution of small, harmful cholesterol molecules and large, harmless ones despite treatment with medication.
In contrast, omega3 fatty acids (fish, flaxseed, hempseed, fish oil), low-carbohydrate diets, niacin (Vitamin B9) and niacin in combination with statins (cholesterol-lowering medication), as well as regular exercise and weight loss have all been shown to effectively increase the size of LDL particles.
In this chart, you can get an overview of how you can change the markers and thus the risk of future cardiovascular disease through lifestyle:
What about those eggs? Can you eat them?
It's okay to eat eggs. Eggs are a healthy source of both a mix of fatty acids and protein, and it's best to eat organic eggs to minimize the toxic load. Eggs can be included in the daily diet, but of course, everything in moderation. The recommendations say that you can eat about one egg a day, an average of seven eggs a week, without an increased risk of cardiovascular disease.
Conclusion: The truth is nuanced
All in all, the truth about cholesterol is much more nuanced than what standard measurements can show. When you analyze a typical cholesterol profile blood test, you get numbers on these parameters:
The individual parameters have limit values (in brackets) that should preferably be adhered to, but there is a very important factor in the relationship between the numbers! Thus, a high HDL can reduce the risk of a high LDL, as the ratio between the two is important. The lower the ratio the better.
How do you know if high cholesterol is dangerous or not?
The easiest way is to get a carotid artery scan and see what your carotid arteries look like. How thick is the vessel wall? If the vessel wall is thickened because of fat accumulation, then yes, you're at risk of damage and future disease.
Is there even plaque formation? And if so, how large and active are those plaques? Are they old changes or are they fresh?
All of this information can be obtained from a simple ultrasound scan.
What to eat if you have "high cholesterol"?
Depending on what the tests show, there may be different advice for each individual. It is always an individual assessment, both in terms of predispositions and current situation, that determines the advice for each person. But overall, there are some common denominators for dietary advice if you are at increased risk of cardiovascular disease:
Gain insight into your risk of developing cardiovascular disease
Have you had a high cholesterol level measured in the past and want insight and advice about it? Or do you want to find out if you carry risk markers for developing cardiovascular disease?
With a health check-up, we give you a comprehensive insight into your health. We give you the knowledge you need to adjust your lifestyle and optimize your health. Based on the results of the examination, we help you to prevent any risk factors and boost your wellbeing and quality of life. Read more about our health check-ups here: https://capio.dk/specialer/helbredsundersoegelser/
At Capio's nationwide hospitals, you will meet some of the country's most skilled and experienced specialists who work together to give you the best possible treatment. We guarantee you peace of mind and high quality and put you at the center every step of the way.
Contact our skilled medical secretaries via Capio Online Service. Login with MitID so you can get your questions answered safely and securely. We are ready to answer your inquiries within opening hours.