1.31 High Cholesterol and Heart Disease
Cholesterol is a fatty substance (lipid) made in the liver that is important in the function of every cell in your body. Since the liver makes all the cholesterol that you need, eating dietary cholesterol is not needed and simply significantly increases blood cholesterol levels which is known to raise the risk of atherosclerosis and thus heart disease and stroke.
Cholesterol is not considered an essential nutrient…there is no such thing as a dietary cholesterol deficiency. Also, saturated fat intake and trans fats in the diet lead to high blood cholesterol levels as well, so our intake of saturated/trans fats (which also are not essential nutrients) should be as low as possible. Foods that contain cholesterol (animal based foods) universally will have significant amounts of saturated fat as well. The Institute of Medicine (IOM) states that any dietary intake of cholesterol, saturated fat and/or trans fat raise blood LDL cholesterol, thus no tolerable upper limit can be set1. Thus the ideal diet would not contain ANY of these harmful fats. Only a whole food plant based diet free of oil can achieve zero cholesterol/saturated/trans fat in the diet and thus is ideal to halt and reverse atherosclerosis.
It has been well shown that the higher your blood cholesterol levels, the more atherosclerotic plaque builds up in the wall of the arteries leading to a higher risk of heart attack, stroke and death. Some authorities believe that a person’s blood cholesterol levels is the only significant risk factor for atherosclerosis. Meaning if blood cholesterol levels are low enough, other traditional heart disease risk factors do not matter nearly as much2.
When atherosclerotic plaque in the walls of the arteries themselves are examined…it is made up of cholesterol! Also, when herbivore animals such as rabbits or monkeys are fed diets high in cholesterol and saturated fat such as meat and egg yolks, they develop atherosclerosis quite easily3. These animals NEVER develop atherosclerosis out in their natural environment where they are nearly 100% plant eaters which is a completely cholesterol free, saturated fat free diet. Blood cholesterol levels of neonates (newborns) and herbivorous animals such as primates (who do not develop atherosclerosis in their natural environment) are remarkably low with a total cholesterol under 150 mg/dL and and LDL around 50-70 mg/dL and thus it has been concluded that these levels are considered “physiologically normal” in humans as well4. Above these levels, atherosclerosis can develop.
Dietary Cholesterol Basics
Having high cholesterol blood levels is most commonly from diets high in cholesterol and saturated fat. Cholesterol is found exclusively in animal based foods such as meat (beef/pork/poultry), seafood (fish/shrimp) and dairy/egg products. There is no cholesterol in plant based foods including in any fruit, vegetable, bean, grain or nut/seed. Likewise, saturated fats are found predominately in the same animal based food products. There is very little saturated fat in any plant food with rare exceptions.
It is important when considering proper nutrition to think about the whole food and not just the individual nutrients. Nobody eats “cholesterol”. They eat meat, eggs or dairy that contain cholesterol (and saturated fat). Why do people eat these animal foods? Well…there is no nutrient in animal foods that you are not able to get in a healthier form from plant based foods. Micronutrients such is vitamins and minerals are found in higher concentration in plant based foods on average and health promoting phytonutrients are found exclusively in plant foods.
People eat animal based foods for pleasure, culture, habit and convenience, not for nutrients. Protein can be obtained exclusively from plants (the strongest animals like elephants and gorillas are herbivores) and it is healthier to obtain protein from plants. When protein is obtained from animal foods, the baggage of dietary cholesterol and saturated fat comes with it. Eating animal foods for protein is like eating a Snickers bar to get heart healthy nuts, but many unhealthy ingredients come along (such as sugar) as baggage. Just eat plants for protein/nutrients and avoid the negative effects of dietary cholesterol, saturated fat and other toxic substances completely!
Comparing two protein sources, one from a plant and one from an animal, will allow us to see how plants foods are superior nutritionally for health. Below shows the nutrition label on ground beef versus black beans.
Since the black beans are a plant based food, there is no dietary cholesterol. Black beans also have no saturated fat. The equivalent amount of beef however has 85 mg of cholesterol, not to mention 9 g of harmful saturated fat and overall 71% of calories from fat! Compare this to the black beans which have zero calories from fat. Remember…the fat you eat is the fat you wear from your lips to your hips they say! Eating the black beans has the extra benefit of weight loss which is important considering 80% of adult Americans are overweight or obese.
Another comparison of boneless skinless chicken breast to broccoli demonstrates that broccoli has half the fat, zero cholesterol and is still quite high in protein (recall men only need 55 g or protein per day and women 45 g and too much is harmful).
For some reason leaner meats such as boneless skinless chicken are considered by many to be “healthy” and they are indeed lower in calorie density than other meats. However you can clearly see by examining the cholesterol/saturated fat content of chicken that even if a meat is considered “lean”, there is still a significant amount of dietary cholesterol which still major negative health impacts. Just because a meat is “leaner” making it less toxic to cardiovascular health does not mean it is healthy for you…it just means it is less toxic, but still toxic.
Recommendations for Dietary Cholesterol Intake
The USDA and the World Health Organization recommends “eating as little cholesterol as possible” however does not actually say to eat zero cholesterol. They show an eating pattern which would range from 100-300 mg of cholesterol per day. That is like saying “don’t smoke cigarettes” but then showing a person smoking only a half pack per day. Ideally, no cholesterol should be eaten at all as clearly shown by the significant effects of a 100% plant based diet (cholesterol free) on cardiovascular disease as you learn about here on HeartStrong.com.
Dietary Sources of Cholesterol
In the US, eggs and chicken have been the top two sources of dietary cholesterol in the recent years. Here are the cholesterol content of some common foods:
Cholesterol Absorption and Metabolism
One very important concept to understand about dietary cholesterol intake relates to how cholesterol is absorbed by the gut. There is a large amount of variation from person to person in regards to how much of the cholesterol that they eat actually gets absorbed, anywhere from 25-80%. Thus blood cholesterol levels may be minimally affected in some people based on dietary cholesterol intake while dramatically affected in others. For example, one person may eat 300 mg of cholesterol and absorb only 75 mg (25%) while another person eats the same 300 mg of cholesterol and absorbs 240 mg (80%)! On average most people absorb 50-60% of dietary cholesterol.
Another important concept is that of the “saturation” of gut receptors for the absorption of dietary cholesterol. Once you reach a certain intake of dietary cholesterol, you have “saturated” your gut’s ability to absorb any more cholesterol into the blood stream. Thus once you reach this “saturation point”, adding even more cholesterol to the diet will not have much of an effect on blood cholesterol levels. This is very important to understand to help us see why many research studies done on dietary cholesterol can be misleading which we discuss below.
So if you measure blood cholesterol levels in a group of people say, after eating a breakfast with 2 eggs every day for a month (about 400 mg of cholesterol) and add just one more egg daily to make 3 eggs (600 mg of cholesterol), you will not see much of a difference. Their cholesterol absorption receptors were already saturated by the cholesterol in the 2 eggs, so adding the 3rd egg did not have much of an effect.
However try measuring blood cholesterol levels in a group of people after eating a breakfast of oatmeal every day for a month (cholesterol free) then adding 2 eggs daily. You will see a BIG difference increase in the blood cholesterol levels in this situation. When they were eating only oatmeal, their cholesterol absorption receptors were not saturated and had the capacity to absorb a large amount once the eggs were introduced to the diet.
This phenomenon is well described in this publication5 in the American Journal of Clinical Nutrition and depicted in the graph below:
The authors concluded “Serum cholesterol concentration is clearly increased by added dietary cholesterol but the magnitude of predicted change is modulated by baseline dietary cholesterol. The greatest increase is expected when baseline dietary cholesterol is near zero, while little, if any, measurable change would be expected once baseline dietary cholesterol was > 400-500 mg/d. People desiring maximal reduction of serum cholesterol by dietary means may have to reduce their dietary cholesterol to minimal levels (< 100-150 mg/d) to observe modest serum cholesterol reductions while persons eating a diet relatively rich in cholesterol would be expected to experience little change in serum cholesterol after adding even large amounts of cholesterol to their diet. Despite modest average effects of dietary cholesterol, there are some individuals who are much more responsive (and others who are not).”
Thus adding dietary cholesterol to someone who does not consume any will significantly increase blood cholesterol levels and vice versa. Removing cholesterol completely from a person’s diet will have a significant benefit to reduce blood cholesterol levels. Having said that, there is significant individual variability from person to person.
In summary, dietary cholesterol intake considered by many to be at a healthy low amount such as 100-200 mg/day, results in a very high percentage of cholesterol getting absorbed increasing blood cholesterol levels. Since cholesterol is not an essential nutrient and is packaged with other substances harmful to cardiovascular health (saturated fat, trans fat, animal protein, heme iron and more that you can read about here), the ideal heart healthy diet would have zero dietary cholesterol which is a 100% plant based diet.
Dietary Cholesterol Debate? No…there is No Debate.
Some studies have questioned the importance of dietary cholesterol intake in the past in regards to blood cholesterol levels. This culminated in a comprehensive review of the published research on dietary cholesterol and heart disease done well in a Cochrane Review in 2015 which concluded that the available studies “lacked the methodologic rigor to draw any conclusions.”5
There is a good reason why and it relates to the “saturation of cholesterol receptors” in the gut that we discussed above. Many studies on dietary cholesterol (some funded by meat/dairy/egg industry) were designed specifically to compare groups of people with a moderate dietary cholesterol intake to a group where extra dietary cholesterol (frequently eggs) is given. Blood cholesterol levels are then checked and little difference is seen between the moderate cholesterol consumption and high cholesterol consumption groups. This again has to do with “saturation” of cholesterol absorption in the gut. Your body can only absorb so much dietary cholesterol. Thus, the effect that dietary cholesterol has on blood cholesterol levels decreases significantly as you increase cholesterol intake to very high levels.
As an example, when groups of people eating 300 mg of cholesterol per day versus 400 mg versus 500 mg are compared, little to no difference in blood cholesterol levels are seen (see the small difference between these intakes on the figure above). However, if a group of people with zero cholesterol intake was compared (a plant based diet), a major difference would be noticed.
Industry funds studies designed this way to get positive conclusions about nutrients in their product (i.e. cholesterol) that have historically been considered harmful to health to introduce confusion and doubt into the public’s mind. Media loves to report controversial research findings which further propagate false information. This was clearly seen in the recent saturated fat debacle as well.
Designing cholesterol studies in the above manner to get negative results is like comparing death rates in car crashes at different speeds. If you chose specifically to examine car crashes at 80 mph versus 100 mph vs 120 mph, you would see that 100% of people in the car crashes die and thus conclude that speed is not an important factor in car crash deaths since everyone died regardless of the speed. What would happen if you included a group of crash tests at 20 mph or 0 mph (not driving at all)? You would notice 100% survival rate! This is exactly like cholesterol studies…zero cholesterol diets (plant based diets) are never included thus making it appear as though dietary cholesterol intake does not have a significant effect when clearly it does.
Having said that, it is known that about 25-30% of people are “hyperresponders” in regards to dietary cholesterol absorption and intake. Meaning eliminating dietary cholesterol completely in these 25-30% of people would have a dramatic effect on lowering blood cholesterol levels. Thus, we need to be cautious looking at the average change in blood cholesterol within a group of people on a plant based diet. Those 25-30% hyperresponders will get dramatic improvements in their blood cholesterol, but a small percentage who are genetically resistant to cholesterol absorption in the first place will have a less dramatic result (however still some improvement). Remember though, even if you are not a hyperresponder to dietary cholesterol absorption, cholesterol comes packaged with harmful saturated fat, trans fat, animal protein and other substances harmful to heart health.
This “hyperresponder” scenario may be the case in a powerful story told by the past president of the American College of Cardiology here. Dr. Kim Williams M.D. thought he was eating healthy, mostly chicken and fish with lots of fruits/vegetables and no junk/processed foods. When he discovered his LDL cholesterol was 170 mg/dL, he quickly adopted a 100% plant based diet (free of dietary cholesterol). Within 6 weeks his LDL dropped to 90 mg/dL. He is quoted as saying “I don’t mind dying…I just don’t want it to be my fault.”
While it is well known that there is significant individual variability of how dietary cholesterol intake affects blood cholesterol levels, overall it is clear that plant based diets clearly lower cholesterol as seen in this meta analysis6.
Having said all that, multiple organizations including the American Heart Association (AHA), American College of Cardiology (ACC), the World Health Organization (WHO) and the United States Department of Agriculture (USDA) have independently reviewed the research and have concluded that dietary cholesterol raises blood cholesterol levels and since it is not an essential nutrient, should be significantly reduced as low as possible in the diet. Again, the only diet that gets you to zero cholesterol in your diet is a 100% plant based diet.
While chicken and eggs are the #1 and #2 source of cholesterol in the American diet, for some reason they are still wrongly considered by many as healthy to eat. As you can tell that can’t be farther from the truth. Here is a good “meta-analysis” which is a statistical study of all dietary cholesterol clinical trials showing a “dose response” of egg consumption and the risk of cardiovascular disease and also diabetes7. Thus, the more eggs that you eat, the higher the risk for cardiovascular disease and diabetes.
Simply remember that the only diet ever shown (on more than 1 occasion) to reverse heart disease (atherosclerosis) published in major peer reviewed journals such as Lancet and JAMA is one that is completely free of dietary cholesterol. Read more about reversing heart disease here.
Blood Cholesterol Levels
When a patient gets a cholesterol blood test, four parameters are measured. These are the total cholesterol, LDL cholesterol (“Low Density Lipoprotein” a.k.a. the “bad cholesterol), HDL cholesterol (“High Density Lipoprotein” or the “good cholesterol”) and triglycerides (technically not a form of cholesterol).
Authorities use the below references for normal blood cholesterol ranges8:
– Total cholesterol (normal < 200 mg/dL)
– LDL cholesterol (normal < 100 mg/dL)
– HDL cholesterol (normal 40-49 mg/dL in men and 50-59 mg/dL in women)
– Triglycerides (normal < 150 mg/dL)
Many nutrition authorities advocate a total cholesterol of < 150 mg/dL arguing that current goals of < 200 mg/dL are not aggressive enough. The rate of heart disease and atherosclerosis is indeed markedly reduced and nearly absent when total cholesterol is able to be lowered to < 150 mg/dL and LDL to 50-70 mg/dL degree by diet alone with the use of drugs9. Interestingly, “vegans” (100% plant based, but not always “whole food plant based”) have an average total cholesterol of 146 mg/dL and LDL of 69 mg/dL while the average American is at 196 mg/dL and 123 mg/dL10. These high average blood cholesterol levels in Americans is a major force causing 50% of American’s to develop some sort of cardiovascular disease in their lifetime.
It is also important to note that rare genetic cholesterol disorders do exist. In theses instances, adopting a plant based diet is even more important. Familial hypercholesterolemia is inherited and affects about 1 in 500 people. In this situation, receptors for LDL cholesterol uptake into cells are lacking and blood LDL cholesterol levels remain quite high, frequently > 300 mg/dL. While there is no published data on plant based diets in this setting, anecdotal stories show many get significant improvement in the blood cholesterol levels, however many will still need medication to reach optimal blood cholesterol levels.
Lastly, besides reducing cholesterol intake in your diet, exercise and weight loss has been shown to lower cholesterol levels as well. As a general rule, every pound of weight loss will result in about 1 point decrease of total cholesterol. Saturated fat intake also significantly increases blood cholesterol levels. In general, for every 1% increase in saturated fat in your diet there will be 2% increase in your blood LDL cholesterol level.
Medications for High Cholesterol
While many medications exist to lower cholesterol, only one class of drugs known as the “statins” have been shown consistently to reduce heart attack, stroke and death risk in multiple research trials. While the risk reduction these medications provide can have a major impact on cardiovascular disease on a large population basis, they are frequently criticized due to side effect risk and a statistic called the “number needed to treat”. For primary prevention (preventing the first cardiovascular event), a total of 167 people would have to be treated for 4 years to prevent 1 death, thus 166 people will not get a mortality benefit and have to take the risk of side effects of statins11. The benefits of statin therapy are more clear for secondary risk reduction (preventing the second event). However, a whole food plant based diet and other lifestyle changes are markedly more effective at halting and reversing atherosclerosis. Ornish et al showed 99% of patients halted and/or reversed their coronary artery disease at 5 years with a plant based diet and lifestyle changes12.
Some examples of statin drugs (HMC Co-A reductase inhibitors) are:
– Rosuvastatin (Crestor)
– Atorvastatin (Lipitor)
– Simvastatin (Zocor)
– Pravastatin (Pravachol)
The American College of Cardiology Guidelines for treating high cholesterol recommend their use in the following 4 situations:
– LDL > 190 mg/dL
– 10-year heart attack/stroke risk > 7.5% which you can calculate here
– Diabetes
– Clinically significant vascular disease (ASCVD – atherosclerotic cardiovascular disease)
Here is a flowsheet to see the ACC/AHA recommendations for cholesterol treatment.
Another class of drugs used to treat cholesterol are the PSK9 inhibitors such as evolocumab (Repatha) and alirocumab (Praluent). These drugs are “monoclonal antibodies” that bind to and inactivate a protein in the liver called proprotein convertase subtilisin kexin 9 (PSK9). This results in more LDL cholesterol being transported into the liver for breakdown and metabolism. While these injectable drugs do improve blood cholesterol levels, their overall affect on cardiovascular disease and mortality is not yet clear. They are currently only recommended to patient’s who still have high LDL cholesterol levels despite maximum tolerated statin therapy. This will be mostly for those rare instances where familial (genetic) hyperlipidemia is present as discussed above.
HDL Cholesterol
The above discussion has focused mostly on total cholesterol and LDL cholesterol, however HDL cholesterol or “High Density Lipoprotein” is also important to discuss when talking about cholesterol.
The HDL cholesterol has always been referred to as the “good cholesterol.” HDL cholesterol participates in “reverse cholesterol transport”, thus having higher levels is thought to help remove cholesterol from tissues and bring it to the liver for recycling. Many studies show that higher HDL cholesterol levels lower the risk of cardiovascular disease (inverse relationship). Despite this, there has never been a medication that raises HDL cholesterol levels AND also lowers the risk of cardiovascular disease. Medications like niacin or torcetrapib (long story behind this one13) significantly raise HDL cholesterol…but do not prevent heart attack, stroke and death? Why is this?
Perhaps the more important consideration for HDL cholesterol is not the actual number on a blood test, but the efficiency of HDL cholesterol to actually do the removing of cholesterol from tissues. This is called the “HDL efflux capacity”. The higher the HDL efflux capacity, the lower the risk of cardiovascular events14.
This explains an interesting scenario in Milano Italy where a mutation in “Apolipoprotein A-1” was discovered which results in very low HDL levels, but NO cardiovascular disease. The HDL that is present in people with this mutation has a very high efflux capacity protecting them from atherosclerosis. The concept of HDL efflux capacity could also explain why those on a 100% plant based diet see a lower HDL cholesterol level (as all blood cholesterol levels go down), but a dramatic decrease in cardiovascular disease15. Perhaps the HDL efflux capacity of those on a plant based diet is enhanced.
Miscellaneous Cholesterol Factors
Liproprotein (a): The molecule lipoprotein (a) a.k.a. Lp(a) or lipoprotein “little a” is an independent risk factor for developing cardiovascular disease. A person’s blood level of Lp(a) is genetically determined and about 20% of people have elevated Lp(a) levels. While historically research has shown that diet and lifestyle changes do not appear to have a major effect on Lp(a) levels, recently there is evidence that a plant based diet does indeed lower Lp(a) levels16. Niacin improves Lp(s) levels, however data is lacking to show that using niacin to reduce Lp(a) lowers cardiovascular risk despite lower blood Lp(a) levels. Here are the ranges for Lp(a):
Desirable: < 14 mg/dL (< 35 nmol/L)
Borderline risk: 14 – 30 mg/dL (35 – 75 nmol/L)
High risk: 31 – 50 mg/dL (75 – 125 nmol/L)
Very high risk: > 50 mg/dL (> 125 nmol/L)
LDL Cholesterol Particle Sizes: We have focused on the total level of blood LDL in the above discussions, however there is more to the story. Two people may have the exact same blood level of LDL cholesterol, but that LDL cholesterol may confer different risks of developing cardiovascular disease depending on what is called the “LDL particle size”.
In general, LDL cholesterol can be separated into “small dense LDL” or “large buoyant” LDL particles. Small LDL particles are much more likely to contribute to atherosclerotic plaque build-up. While not scientifically accurate, think of smaller cholesterol particles being able to squeeze their way into the artery walls easier causing plaque formation. Larger LDL particles do NOT contribute as much to plaque development (although they still do to some degree). Think of larger LDL particles bouncing around in the arteries having a hard time penetrating the endothelial lining thus not contributing as much to plaque build-up.
Advanced lipid profile testing is widely available to measure LDL particle size. So what if your LDL particle size profile is not favorable? There are no formal recommendations from the American Heart Association or American College of Cardiology about diet/lifestyle therapies or medications to improve the LDL particle size ratio, however as with Lp(a), plant based diets are effective having reduced the small-dense LDL blood cholesterol levels by 30% in just 4 weeks16.
Triglycerides: While triglycerides are not technically “cholesterol”, they are indeed related to cardiovascular disease risk and are routinely measured on a lipid profile so we will briefly discuss them here. Triglycerides are a type of fat that is the main type of fat stored in the human body and can be separated into saturated fat and unsaturated fats discussed elsewhere on HeartStrong.com. Higher blood triglyceride levels increase the risk of cardiovascular disease.
It is important to know that blood triglyceride levels are inversely proportional to HDL cholesterol levels, meaning when the HDL is low, triglycerides are high and vice-versa.
Exercise and weight loss significantly lower blood triglyceride levels. Reducing refined carbohydrates is also key. Lastly, uncontrolled diabetes type II increase triglyceride levels significantly, so better control of diabetes will improve triglyceride numbers.
There is little data to support the use of medications to lower blood triglyceride levels AND reduce cardiovascular risk, similar to HDL cholesterol. In general, only if fasting triglycerides are > 500 mg/dL are medications routinely used. With the proper diet/lifestyle, the only situation medications should be needed for high triglycerides would be in rare genetic cholesterol disorders.
Fish oil has been used for years to lower blood triglyceride levels and it does indeed do so. However multiple randomized clinical trials show that despite lowering triglyceride levels, fish oil does not reduce cardiovascular disease risk17 and the risk of aggressive prostate cancer is increased by fish oil in men. The ACC/AHA guidelines agree that fish oil has not been shown to reduce cardiovascular risk.
Summary and Conclusions
Cholesterol is a fatty substance crucial to the function of all cells in your body, however it is not an essential dietary nutrient as it is made in the liver. Cholesterol, saturated fat and trans fat in the diet leads to higher blood cholesterol levels and higher cardiovascular disease risk and thus the consumption of these non-essential fats should be limited as much as possible, ideally to none at all. Cholesterol is only found in animal based foods and is absent in plant based foods. A whole foods, plant based diet contains zero cholesterol and is ideal for optimal cholesterol levels and reversing atherosclerosis. While the amount of dietary cholesterol absorbed varies from 25-80% from person to person, there is no controversy that dietary cholesterol intake should be as low as possible. Ideal LDL cholesterol levels should be around 50-70 mg/dL and at that level, atherosclerosis should not develop and can even reverse, especially when done without the use of cholesterol medications.
Remember, even though 40-50 million Americans take statins, heart disease is still the #1 killer in America, so these drugs are obviously not the answer to eliminate heart disease, but dietary changes may indeed hold the key to a cure. Diets simply low in cholesterol (but not zero cholesterol), such as the Mediterranean Diet which traditionally gets more than 90% of calories from plant sources, is far better than the Standard American Diet, but it has never been shown to reverse heart disease. The ideal approach to treating high cholesterol levels resulting in lower heart disease and stroke risk is to go completely on a cholesterol free, very low saturated/trans fat diet such as the whole foods plant based diet.
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