The New Truth About Cholesterol

For most of my adult life, I usually avoided eggs. I had read that since yolks are full of cholesterol, eating them would raise my blood cholesterol and harm my heart health. Then, around three years ago, to lose a few kilos I reduced simple carbs and added more protein to my diet—including eggs. But I wondered what that would do to my cholesterol levels, so at my next medical check-up, I asked for a blood test. My doctor surprised me with this response: “We were wrong about that all along. The best research says you don’t need to avoid eggs.”

To reassure me, she ordered the blood test. The results? Same healthy cholesterol levels as before. It got me wondering: How many other people were unnecessarily avoiding eggs and other foods based on old information? And now that I was in my 50s, what else should I be doing to make sure my cholesterol stayed in the safe zone? My research turned up some surprising facts.

The Basics

High cholesterol is a major risk factor for cardiovascular disease, as are high blood pressure, smoking and being overweight or obese. According to the largest ever study of global cholesterol levels, led by Imperial College London and published in 2020, high cholesterol is responsible for about 3.9 million deaths annually worldwide. Keeping your cholesterol in check lowers your risk.

Cholesterol is a waxy substance produced by our livers and found in our blood and every cell in our body. It helps the body build hormones and vitamin D, maintain cells, digest fatty foods and more. There are two main lipoproteins that carry cholesterol in the blood. Low-density lipoprotein (LDL), the main type of ‘bad’ cholesterol (though there are others), delivers fatty particles throughout your body. But if there’s too much LDL, the build-up on artery walls can block blood flow and lead to blood clots. This can cause a heart attack or stroke. High-density lipoprotein (HDL) is considered ‘good’ cholesterol because it picks up the bad LDL particles and returns them to your liver for excretion.Because cholesterol is such an important factor in our longevity, it’s crucial we know the latest facts. There are some myths floating around about the causes and treatments of high cholesterol. It’s time to set the record straight.

Myth: “Foods that contain cholesterol are unhealthy”

Truth: Some are, but not all

When a blood test shows high levels of LDL cholesterol, or high levels of all the ‘bad’ ones, referred to as non-HDL cholesterol, it’s likely that a major factor will be eating the wrong foods. But just because a food contains cholesterol doesn’t always mean eating it will raise your blood cholesterol. Research in the 1960s linked the two, but several studies in the decades since have put this mistaken belief to rest. It depends more on the food’s saturated fat content. Artificial, or industrial, trans fats from some mass-produced fried and baked foods are also to blame. Trans fats are present in large amounts in partially hydrogenated vegetable fats, such as margarine and vanaspati ghee, as well as foods that are deep-fried or fried in reheated oil. The Food Safety and Standards Authority of India is making efforts to reduce the cap on permissible levels of trans-fatty acids from five to two per cent in oils and fats by 2022.Cholesterol is found in animal products—meats, seafood, egg yolks and dairy products—and the ones high in saturated fats raise blood cholesterol. “The cholesterol and saturated fats reinforce each other when eaten simultaneously, making the effect on the body even worse,” says Martijn Katan, professor emeritus of nutrition at Free University, Amsterdam. The worst culprits are high-fat dairy products and fatty red meats, as well as processed meats, whereas seafood such as prawns and squid, while high in cholesterol, are lower in saturated fat.

For comparison’s sake, one egg weighing 50 grams has two grams of saturated fat; the same amount of shrimp has almost no saturated fat. As for eggs, recommendations vary for how many are safe to consume. Says Professor Katan, “In the Netherlands, we recommend sticking with two to three eggs per week.” The American Heart Association, for its part, says that healthy adults can safely consume one egg per day, and cautions it’s often what might accompany eggs—salami and sausage, which are heavy in saturated fat—that leads to higher dietary cholesterol. However, eggs themselves are a relatively lean, inexpensive source of protein.

So, the best way to improve your diet is to reduce LDL. But how? By replacing saturated fats with unsaturated fats; for example, says Professor Katan, “switching from butter to soft margarine, and cooking with vegetable oils such as sunflower, corn, rapeseed or olive.” These contain linoleic acids and can actually lower your LDL cholesterol. “As for dairy, go low fat—and consider cheese a treat.” He adds that the optimal foods for keeping cholesterol in check include legumes and beans, whole grains like oatmeal and vegetables.

Myth: “If my cholesterol is high, I’ll feel it”

Truth: No; Only a test can tell you

Five years ago, Fredrik Sundell was active and at a healthy weight. But a company health check-up showed his cholesterol levels were borderline high. “I was surprised, because I felt fine,” says the now 49-year-old CFO of a publishing company in Helsinki. “I thought if I had a heart-health problem, I’d know it; maybe I’d have a faster heartbeat or be short of breath.”

The doctor told Fredrik he should try lifestyle improvements to keep it in check; otherwise, he’d have to go on medication. So, Fredrik made an effort to incorporate more fitness into his day, by walking instead of driving and doing more cross-country skiing in winter. Plus, Fredrik says he became more careful about eating healthily—though, he admits, “I wasn’t always an angel.”

You can’t feel high cholesterol. The only way to know if you have it is to get a test. The age at which you are given a cholesterol test at a routine medical check-up—if you don’t have other risk factors—varies from country to country. For example, in India and the United Kingdom it’s 40; in Germany it’s 35; and in France it’s 50. But in some countries, such as the Netherlands, there’s no recommended age for the test; instead, doctors assess whether an individual needs one based on overall risk factors for cardiovascular disease, regardless of age.

Indeed, some experts feel testing should start when people are in their 30s or even their 20s. “Testing cholesterol levels in young people could be life saving,” says Dr Fabian Brunner, a cardiologist at the University Medical Centre Hamburg-Eppendorf. Dr Brunner was lead author of a major international study, published in 2019, that analyzed decades of population-based data on cardiovascular patients. Using the data, the researchers estimated the long-term risk of a cardiovascular event by the time someone was 75 and calculated the potential benefit of lowering non-HDL cholesterol earlier in life. Their results showed that doing so does indeed help protect you from cardiovascular disease later in life. (To calculate your own risk and benefits, go to nonhdlrisk.com.)

As for Fredrik of Helsinki, he is glad he was tested. At his most recent check-up, his doctor was pleased that his cholesterol had not increased further but told him he’d have to try harder to get it down, and to focus on diet. While exercise won’t lower LDL cholesterol—diet is the biggest factor—“it can increase HDL,” notes Professor Ian Graham, head of cardiovascular medicine at Trinity College in Dublin. “And exercise is a marker of a healthy lifestyle.”

Myth: “Statins have bad side effects”

Truth: the side effects from statins are rare

When Ricardo Saénz, a 50-year-old engineer in Madrid, had a check-up around four years ago, his cholesterol levels were within the healthy range, but because he had high blood pressure—a major risk for heart attack and stroke—his doctor said he’d have to reduce his cholesterol, and quickly. “He said if I didn’t, it would be really dangerous.” The doctor recommended Ricardo go on statins right away.

Statins, which are widely used globally and have been around since the 1980s, lower the production of LDL cholesterol by blocking an enzyme in the liver that helps make it. “And they stabilize the plaque in your arteries to stop it breaking off and causing a heart attack or stroke,” says Christopher Allen, head of healthcare at HEART UK—The Cholesterol Charity. “They’re a proven, incredibly effective drug. Statins reduce the chance of cardiac events by 30 per cent.” Your doctor can assess whether you have risk factors that warrant statins.

When Ricardo got home with the prescription, his wife warned him that she had heard statin drugs had side effects. “That did make me hesitate, but I went ahead with my doctor’s orders,” he says. “It’s been four years, and I have had no side effects at all.” The best news: Not only is his cholesterol much lower, his blood pressure is also under control thanks to blood-pressure medicine.

Statins “have fallen victim to the Age of Misinformation,” according to a paper published in 2019 by the European Society of Cardiology (ESC). There are rumours they cause muscle pain, type 2 diabetes, cancer, even dementia. In reality, while the most common side effect reported by statin users is muscle aches, says the ESC, it occurs in less than one per cent of patients and is often alleviated by switching to another brand of statin. As for claims statins cause cancer, that’s “Google scare-mongering,” says Professor Graham. In fact, a 2020 study by Johns Hopkins Medicine shows statins may actually starve cancer cells.

Another example is a purported link between dementia and statin use. “Yet there is no hard evidence of cognitive impairment,” Professor Graham says, “and indeed the risk of vascular dementia is probably reduced.” That’s the second most common form of dementia after Alzheimer’s disease. So, what about statins and Alzheimer’s? A 2016 study looked at 4,00,000 Americans who regularly used statins for at least two years. It found that over a span of four years, the men had a 12 per cent lower risk of getting Alzheimer’s disease and the women had a risk-reduction of 15 per cent.

Though statins worked for Ricardo, they aren’t enough in some cases. “Your doctor may add ezetimibe,” says Allen. Together, these oral medications make for an aggressive treatment. And for the few who are intolerant to statins, there are new injectable medications called PSK9 inhibitors that work by blocking production of a protein in the liver so that the liver can better remove cholesterol from the blood.

Myth: “I can prevent high cholesterol with exercise & diet”

Truth: If it’s genetic, you can’t avoid it

Renee Welling, 60, never worried about her heart health; she worked out “like an Olympic athlete,” doing aerobics and weight training regularly at the gym and maintaining a super-healthy diet that kept the former Toronto model slim and trim. Then, when she was 54, she had her first cholesterol test—and was shocked to discover it was dangerously high. She was a ticking time bomb.

Familial hypercholesterolaemia (FH for short) means you are born with an inability to rid your blood of LDL (bad) cholesterol. It has no symptoms and occurs in around one in 250 of the general population, according to Professor Graham. “It’s genetic. If the condition is inherited from one or, worse, both parents, untreated high cholesterol will often result in a heart attack when you’re relatively young.”

But you won’t know you have FH without a test. “Let’s say one of your parents has a heart attack,” says Allen. “You don’t automatically think it must be because of high cholesterol and that you might have it too.” In reality, he says, “those with FH have it from birth.” In almost all cases, people with FH can’t lower their cholesterol to a healthy level without medication. Renee Welling’s doctor put her on statins—and it worked. Her cholesterol levels are now well within the healthy zone. “Thank goodness I was tested,” she says.

Controlling your cholesterol can mean a longer, healthier life by lowering your odds of having a heart attack or stroke. And it’s possible to get it under control regardless of your age. Says Professor Graham, “The research confirms it’s never too late to treat cholesterol, at least until the mid-80s.” The takeaway: Talk to your doctor about getting tested; keep cholesterol in check with dietary changes (especially limiting saturated fats and high-fat dairy) if you don’t have other heart disease risk factors; and if you need statins, they work, and most people tolerate them well.

Unhealthy Fats: These are foods to avoid

Saturated fats that are harmful to cholesterol levels are found mainly found in dairy products and meat (fatty cuts of meat, especially red, and processed products such as meat pies and sausages). These fats are also found in butter, lard, ghee, coconut oil, and palm oil, as well as in high-fat milk, cream and cheese.

Trans fats of the artificial kind are present in products that mention ‘hydrogenated oils’, ‘partially hydrogenated oils’ or ‘shortenings’ in the ingredients list. Avoid baked goods such as biscuits, pies, cakes, fan, patties, puffs, cakes and pastries as well as fried takeaway foods like burgers and spring rolls, sweets like jalebi, ladoos and fried savouries such as namkeen, as vegetable oils heated to very high temperatures can be high in trans fats.

—With inputs by Ishani Nandi