Scientific consensus panels going back decades established—“beyond a reasonable doubt”—that lowering LDL cholesterol reduces the risk of heart attacks. Consistent evidence “unequivocally” establishes that LDL causes our number one killer, heart disease. This evidence base includes hundreds of studies involving literally millions of people. In other words, “[i]t’s the cholesterol, stupid,” quipped American Journal of Cardiology editor-in-chief William Clifford Roberts. His CV is more than a hundred pages long, and he’s published about 1,700 articles in the peer-reviewed medical literature. Yes, there are at least 10 traditional risk factors for atherosclerosis, but, as Dr. Roberts notes, only one is required for the progression of the disease: elevated cholesterol. All of the other factors, such as smoking, high blood pressure, diabetes, inactivity, and obesity, merely exacerbate the damage caused by high cholesterol.
Phew! you say, because your bloodwork just came back and your doctor said your cholesterol is “normal.” But hold on. Having a normal cholesterol level in a society where it’s normal to drop dead of a heart attack isn’t necessarily something to celebrate. With heart disease the top killer of men and women, we definitely don’t want to have normal cholesterol levels. We want to have optimal levels—and not “optimal” by arbitrary laboratory standards, but optimal for human health.
Normal LDL cholesterol levels are associated with the buildup of atherosclerotic plaques in our arteries even in those with so-called optimal risk factors by current standards: blood pressure under 120/80, normal blood sugars, and total cholesterol under 200. If you went to your doctor with those kinds of numbers, you’d probably get a gold star and a lollipop, or at least a pat on the back. But when ultrasound and CT scans were used to actually peek inside the bodies of patients boasting those numbers, overt atherosclerotic plaques were detected in 38%. Maybe those digits ain’t so optimal after all.
Perhaps we should define an LDL cholesterol level as optimal only when it no longer causes disease. (What a concept!) How would we go about figuring that out?
When more than 1,000 men and women in their forties were scanned, most of those with “normal” LDL levels under 130 had frank atherosclerosis. No atherosclerotic plaques were found only when LDL was down around 50 or 60, which just so happens to be the level most people had before our diets changed to what they are today. The majority of the global adult population had LDLs around 50 mg/dL. So, average values today are regarded as normal based on a sick society. What we want is a cholesterol level that is normal for the human species, which is considered to be around 30 to 70 mg/dL (or 0.8 to 1.8 millimoles per liter).
Although an LDL level in this range might seem excessively low by modern American standards, it is precisely the normal range for individuals living the lifestyle and eating the diet for which our ancient ancestors were genetically adapted over millions of years: a diet centered around whole plant foods. Given that the LDL level our body was designed for is less than half of what is presently considered as “normal,” it’s no wonder we are awash in a pandemic of atherosclerotic heart disease.
Why is there a tendency in medicine to accept small changes in risk factors when the goal shouldn’t be just decreasing risk, but preventing plaques from forming in the first place? In that case, how low should we go?
One noted professor of vascular biochemistry noted: “In light of the latest evidence from trials exploring the benefits and risks of profound LDL cholesterol-lowering, the answer to the question How low should we go? is, arguably, a straightforward As low as you can!” How we get there, though, matters. Low may indeed be better, but if we’re lowering our LDL with drugs, then we need to balance the benefit with the risk of pharmaceutical side effects.
There’s a reason we don’t try to drug everyone with statins by putting them in the water. Yes, it would be great if everyone’s cholesterol was lower, but the drugs themselves have countervailing risks. So doctors aim to use statins at the highest dose possible to achieve the largest LDL cholesterol reduction possible without increasing the risk of muscle damage the drugs may cause. Statins also increase the risk of developing type 2 diabetes. However, when you use healthy lifestyle changes to bring down cholesterol, all you get are the benefits—including a significant drop in diabetes risk. But can you get your LDL low enough with only your diet?
Ask some of the country’s top cholesterol experts what levels they shoot for, and odds are you’d hear something like an LDL under 70 or so. Just cutting down on the saturated and trans fats found in meat, dairy, and junk, as well as reducing intake of the dietary cholesterol found mostly in eggs, is unlikely to get most people to the target. However, those eating completely plant-based diets can average an LDL that low. It’s no wonder plant-based diets are the only dietary patterns ever proven to reverse the progression of coronary heart disease.
Excerpted from HOW NOT TO AGE: The Scientific Approach to Getting Healthier as You Get Older by Michael Greger. Copyright © 2023 by Michael Greger. Reprinted with permission from Flatiron Books. All rights reserved.
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