Should I worry about my cholesterol levels?  Worry about inflammation instead!

Should I worry about my cholesterol levels?

Recently, new guidelines were introduced for what is deemed to be a healthy cholesterol level. While formerly, it was adviced to introduce cholesterol lowering drugs when your 'bad' cholesterol level amounted to over 2.5 mmol/litre, that number now dropped to 1.8.
This big drop will probably result in a vast increase of people that are being administered cholesterol lowering drugs.

But what if I told you, cholesterol is a poor marker for heart health?

For decades, cholesterol testing has served as that warning for many. An elevated level of "bad" LDL cholesterol has been just the warning people needed to change their ways. It has played that role for several reasons. People like tests because the results seem objective. Reliable measurement of cholesterol is easy and relatively inexpensive. It makes sense biologically. LDL cholesterol, a protein-wrapped package containing fat and cholesterol, tends to slip out of the bloodstream and lodge in blood vessel walls, forming the plaque that leads to clots and heart attacks.

And it makes sense statistically. The correlation between lowering your LDL and lowering your chances of having a heart attack or developing other forms of heart disease is well documented. Indeed, exercise and dietary changes are good for the heart partly because they lower LDL cholesterol levels.

Flawed testing method

But for all its virtues, cholesterol testing is seriously flawed. Research has shown that only about 50% of the people who have heart attacks have high LDL. If LDL levels are supposed to be an alarm, then it's not going off for half of those who might benefit from a wake-up call.

This shortcoming presents two problems. First, and most obviously, many people at risk are being missed. So there's a need for a different test that will "capture" those who slip through the fingers of cholesterol screening.

Second, because cholesterol screening does miss so many incipient heart attacks, it suggests that cholesterol doesn't adequately explain heart disease.
Inflammation seems to be that explanation, and C-reactive protein (CRP), a by-product of inflammation, may provide the test.

Inflammation causes heart attacks

Experts who study blood vessels, plaque, and heart attacks in minute detail have been developing an inflammatory explanation for heart attacks. They've described a process quite different from the clogged plumbing analogy. Blood vessels aren't solid pipes, but slender tubes of layered, living tissue, some of it quite delicate. LDL cholesterol doesn't simply lodge in arterial walls-it injures them. And like injuries elsewhere in the body, this stirs up an inflammatory response. Swarms of cytokines, macrophages, and other cells swoop in. They enlarge and transform deposits of LDL cholesterol into accumulations of fat-laden foam cells sealed by fibrous caps of collagen.

Other inflammatory molecules can so weaken a fibrous cap that eventually it bursts open. The contents of the plaque spill out and activate clotting factors in the blood. A massive blood clot forms. The result: a blocked artery and a heart attack.

Why C-Reactive Protein?

If inflammation explains heart attacks, then a test that helps doctors gauge inflammatory activity inside the blood vessels might be valuable. CRP is nothing new to medical science as this protein was discovered in 1930 already.

Researchers quickly figured out that it was part of the immune or inflammatory response because levels soared in response to Streptococcus A infection. In fact, doctors have used CRP measurements for decades to monitor patients with lupus, rheumatoid arthritis, and other conditions related to the immune system.

But as a way to screen for heart disease risk? That was a different story. All the momentum and much of the science used to be behind cholesterol testing. Now, however, CRP testing seems ready to catch on for several reasons.


The inflammatory explanation of atherosclerosis and heart attacks has trickled down from rarefied research circles to doctors and the public. Dozens of newspaper, magazine, and newsletter articles have been written about it. People are more likely to get a test-maybe even demand one-if they have some understanding of what's being measured and why. The same goes for doctors.
It's a good predictor of heart disease.

Even if heart attacks were caused by inflammation, CRP testing wouldn't be useful unless it's proved to be a good predictor. In other words, studies have to show that there's a tight correlation between high C-reactive protein levels and the chances of having a heart attack.

To make a long story short, that's just what a series of studies published in prestigious journals has shown. As early as in 2002, it was concluded that CRP outperforms LDL cholesterol as a predictor of cardiovascular risk.
Combined together, the two tests identify different high-risk groups, so using both is better than relying on either alone.

There are other ways to measure inflammation. But C-reactive protein was a better predictor of cardiovascular events (heart attacks, strokes, bypass surgery, or angioplasty) than other inflammatory markers.

Tests for C-reactive protein are now sensitive enough to measure 1 milligram per liter or less. That's a crucial development because it's fairly minor differences at those low levels that sort out cardiovascular risk.

Testing for C-reactive protein is practical too, because a test is fairly cheap and only requires a small amount of blood. In fact, the same blood sample could be sent to a lab for both cholesterol and C-reactive protein testing.

It's possible to classify CRP levels in terms of low, moderate, or high risk.
<1 milligram per liter of blood corresponds to a low risk for heart attack or other cardiovascular problems;
1-3 milligrams per liter corresponds to moderate risk
- >3 milligrams, to high risk.
These cutoffs might change with more research (as have those for cholesterol), but they're a starting point.

You can do something about high levels of C-reactive protein.

Imagine your doctor telling you that a newfangled test of inflammation shows that you have a worrisome level of a telltale protein, but, um, there isn't much you-or she-can do about it. That wouldn't be a popular or helpful test, even if it were a perfect prognosticator of heart attacks.

A big reason behind the growing enthusiasm for C-reactive protein tests is that levels can be lowered.
Statin drugs made their name by lowering LDL; research has shown that they also lower C-reactive protein levels.
Exercise is a great way to bring down your CRP level; losing weight also seems to work.

High CRP/Low LDL

In the study in which C-reactive protein was compared to LDL levels, it was found that cardiovascular risk was actually greater for people in the high CRP/low LDL group than for those in the low CRP/high LDL group.
Clearly, cholesterol testing would have missed people in the high CRP/low LDL group.
So, CRP testing can be very useful in people with normal cholesterol levels who still may be at risk for cardiovascular disease.

Improving your health

No test, no matter how good it is, changes anyone's health. It's what we do in response that matters. Statins have put a pharmaceutical face on heart disease prevention, but the old truths about getting exercise, eating right, and not smoking still hold. If the CRP test gets more people to follow that advice, then it may be worthwhile.

Do you really need cholesterol-lowering drugs or can you drop cholesterol naturally?
In the end it will be your doctor who determines whether or not you will be put on cholesterol-lowering drugs, but be aware these drugs fight symptoms of heart disease, while having quite a few undesirable side-effects.
You may try to drop your cholesterol naturally with a healthy lifestyle and diet, which will decrease inflammatory markers in your blood.
Sometimes your doctor is prepared to wait until you adapt your lifestyle and

- decrease your body weight
- stop smoking
- stabilise your blood sugar level
- eat more fresh foods to which you aren't allergic or sensitive
- avoid chronic stress situations
- move more
- get enough sleep

What type of nutrition will make your heart healthy again?

Dietary guidelines that are handed out with a cholesterol lowering diet is decreasing saturated fats and increasing unsaturated fats, sometimes even recommending products that are enriched with plant sterols.
However, just focusing on a diet that lowers cholesterol will not necessarily also lower inflammation markers.
The most effective cholesterol lowering foods are fish oil, soy (best combined with probiotics or in pre-fermented form as natto), red yeast rice, green tea, and garlic.

Instead, it is better to focus on a diet that will lower inflammation markers.
The type of food that will lower inflammation is food that hasn't been heavily processed that will not spike your blood sugar levels. It also helps to avoid foods to which you are allergic, intolerant or sensitive.
Moderate your alcohol consumption and try to limit your calorie-intake so that you won't gain weight when you are already at a healthy weight.
The most effective anti-inflammatory foods are anti-oxidant rich foods such as green leafy vegetables, cruciferous vegetables (bok choy, broccoli), celery, beets, blueberries, pineapple, salmon, bone broth, walnuts, coconut oil, chia seeds, flax seeds, turmeric, ginger.

Conclusion

When you are aware of possible heart health risks, by all means have yourself tested, but ask for a combined test that will give both the values for your cholesterol and your C-Reactive Protein.
After that.. get moving and make sure you drop your heart pressure and your body weight by eating right.
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