Cholesterol: why one size doesn’t fit all

This cardiologist argues that there’s no one right way to treat high cholesterol. We’re all individuals and need individual responses.

The UK’s Dr Ali Khavandi has an interesting mix of skills. He’s a surgeon who inserts balloons into arteries to expand them and pacemakers into chests, but he’s also delved into the role of diet and lifestyle in heart disease. Which makes him a good all-rounder when it comes to managing cholesterol.

As he says, ideas on this fall into two broad camps.

The first is the traditional medical one, backed by industry-sponsored research, which argues that high cholesterol leads to a heart attack, and the best defense against this is medication, i.e. statins.

The second camp believes cholesterol is necessary for a well-functioning mind and body, and that the widespread prescription of statins represents the influence of ‘Big Pharma’ on doctors.

Medication has a place though, and Dr Khavandi would argue that solutions for most people are likely to be found somewhere between those two points of view.

He says people with high cholesterol can be split into three groups.

In group 1, cholesterol is genetic. These people may be slim and exercise regularly, but no amount of exercise or healthy eating will lower their cholesterol. They’ll need statins. This only affects about one in 250 people though — around .4% of us.

Those in group 2 have other metabolic issues in addition to high cholesterol. These might include excess belly fat, high blood sugar, high blood pressure, sleep apnea, gout, or atrial fibrillation (disturbed heart rhythm). They could be diabetic or pre-diabetic.

This group benefits from diet and lifestyle changes. Switching from a high sugar/high carbohydrate eating pattern to one focused on minimally processed foods that keep us feeling satisfied for longer improve insulin sensitivity, reduce belly fat, and lower cholesterol.

While some medical sources still encourage a low-fat diet, including cholesterol-lowering margarines, Dr Khavandi points out that a lot of the information about low-fat diets and avoiding saturated fat is ‘historical’ (i.e. out of date).

This is counter to the standard dietary advice that saturated fat is unhealthy, and that red meat is one of the worst offenders.

He says: “Eating a good-quality steak, which is high in protein, improves appetite regulation, which can help bring metabolic disorders under control. It’s very similar to what the GLP-1 medications like Ozempic do; they shut off your hunger.”

Saturated fat can increase cholesterol readings, so if we’re concerned about that we should keep our meat lean and eat it in moderate amounts, and be sensible with butter rather than going overboard.

But the idea that we should avoid nutritious foods such as meat, eggs and dairy because they contain saturated fat is an old, discredited idea — though one that lingers.

The kind of meat and dairy to stay away from are the fast food and processed meats and the sweetened yoghurts and commercial ice cream.

Regular exercise should also help to improve insulin sensitivity and cholesterol.

The people in Dr Khavandi’s group 3 have high cholesterol but it’s not inherited, they’re not significantly overweight, and there’s no obvious lifestyle cause for it.

Imaging techniques that scan the arteries can help to determine whether diet and lifestyle tweaks and/or medication are needed.

But, he argues, most people with high cholesterol but no other risk factors don’t need a statin. In fact, they probably don’t need to worry about their cholesterol at all.

Photo Source: Paul Gillis