What really matters about cholesterol in the big scheme of things

Cholesterol remains one of the most confusing areas of both nutrition and heart health.

So, I’ll break it all down for you here…

First, you need to know the difference between dietary cholesterol and blood cholesterol. I’ll get right to the point: Focus on blood cholesterol; don’t get too hung up on the cholesterol content of foods.

Here’s why…

Dietary cholesterol is a scapegoat

It’s been known for years that the cholesterol you find in foods is NOT the biggest driver of blood cholesterol levels.

It turns out that the vast majority of cholesterol circulating in your bloodstream is manufactured inside your body — in response to the totality of your diet.

So despite the name, the cholesterol number you see on food labels is fairly meaningless. It’s the overall composition of the food — and especially what type of fats and carbs it contains — that determines blood cholesterol levels.

So whole eggs and meat pose problems not because they’re high in dietary cholesterol, but because they’re also high in animal-based saturated fat. The combination raises blood cholesterol.

Shrimp, on the other hand, are high in dietary cholesterol but very low in fat, so blood cholesterol levels are much less impacted when you eat shrimp (unless you douse them in butter or eat them in large quantities).

Meanwhile, as I explained in last week’s blog, loading up on simple carbs will raise blood cholesterol levels even if those carbs are cholesterol- and fat-free. That’s why the dietary pattern that used to be advocated by the American Heart Association (low-fat, low-cholesterol) ended up backfiring.

On to blood cholesterol: Here’s where doctors and guidelines come into play — and yes, the potential for more confusion…

Blood cholesterol should be your focus

Blood cholesterol is measured with a blood test, and in general, it’s the LDL (bad cholesterol) that is the main focus of treatment.  But whether or not cholesterol-lowering drugs are recommended depends on other factors as well.

The newest guidelines, issued in 2018, bring lots of numbers into an equation in order to estimate the risk of an individual experiencing a heart event over the next 10 years. Any calculated risk greater than 7.5 percent qualifies a patient for statins — no matter what their blood cholesterol number is. So even a person with low LDL can end up getting a prescription for a drug.

For example, patients who have already had a heart event (like heart attack, stroke, bypass surgery, stent), and patients with diabetes are at such a high risk that they are routinely prescribed statins regardless of baseline cholesterol readings.

And because age is such a powerful driver of that calculated risk, many people get offered a prescription simply on the basis of their birth date. Even though that makes theoretical sense — after all, as people get older the chances that they experience a heart event go up — that means all men over 65 and all women over 70 could get offered a prescription.

If you feel that you might fall into this age-driven category and would prefer to avoid statin drugs, ask your physician if you might be a candidate for a coronary calcium scan. The test is safe, not expensive, well-validated, and can help refine risk estimation on an individual basis.

Bottom line: you can stop worrying about the cholesterol content of foods. Focus on overall food quality instead. And know that if you eat a whole food plant-based diet you will automatically reduce your intake of simple carbs and saturated fats, thus helping to keep your blood cholesterol down. And start thinking about blood cholesterol as an important marker of health risk — but not the only one.

Dr. Elizabeth Klodas MD, FACC

By Dr. Elizabeth Klodas MD, FACC

"Diet is a major driver of high cholesterol, but instead of changing the food, we prescribe medications. This never seemed logical to me.” Dr. Klodas has dedicated her career to preventive cardiology. Trained at Mayo Clinic and Johns Hopkins, she is the founder and Chief Medical Officer for Step One Foods. Dr. Klodas is a nationally sought out speaker and has an active role at the American College of Cardiology. Her clinical interests include prevention of heart disease and non-invasive cardiac imaging and she has published dozens of scientific articles throughout her career. Dr. Klodas has been featured on CNN Health for her mission to change how heart disease is treated. An independent study performed at leading medical institutions affirmed the ability of Step One Foods to deliver measurable and meaningful cholesterol-reduction benefits in the real world. The results of the trial were presented at the 2018 American Heart Association’s Scientific Sessions. Dr. Klodas has also authored a book for patients, "Slay the Giant: The Power of Prevention in Defeating Heart Disease," and served as founding Editor-in-Chief of the patient education effort of the American College of Cardiology. In addition to her practice and her duties at Step One Foods, she also serves as medical editor for webMD.