Flashback Friday: Optimal Cholesterol Level

No matter where we live, how old we are, or what we look like, health researchers have discovered that 90% of risk for having a first heart attack can be attributed to nine modifiable risk factors. The nine factors that are threatening our lives include smoking, too much bad cholesterol, high blood pressure, diabetes, abdominal obesity, stress, a lack of daily fruit and vegetable consumption, as well as a lack of daily exercise.

But Dr. William Clifford Roberts, Executive Director of the Baylor Heart and Vascular Institute and long-time Editor-in-Chief of the American Journal of Cardiology, is convinced that atherosclerosis has a single cause, namely cholesterol, and that the other so-called atherosclerotic risk factors are only contributory at most. In other words, we could be stressed, overweight, smoking diabetic couch potatoes, but if our cholesterol is low enough, there may just not be enough cholesterol in our bloodstream to infiltrate our artery walls and trigger the disease. Thus, the only absolute prerequisite for a fatal or nonfatal atherosclerotic event like a heart attack is an elevated cholesterol level.

It was not appreciated until recently that the average blood cholesterol level in the United States, the so-called “normal” level, was actually abnormal, accelerating the blockages in our arteries, and putting a large fraction of the normal population at risk for our #1 killer. That’s cited as one of the reasons the cholesterol controversy lasted so long–an unwillingness to accept the notion that a very large fraction of our population actually has an unhealthily high cholesterol level. Normal cholesterol levels may be terminal cholesterol levels

The optimal cholesterol level, the optimal “bad cholesterol” LDL level, is 50 to 70. Accumulating data from multiple lines of evidence consistently demonstrate that that’s where a physiologically normal LDL level would be. That appears to be the threshold above which atherosclerosis and heart attacks develop.

That’s what we start out with at birth, that’s what our fellow primates have, that’s the level seen in populations free of the heart disease epidemic, but we can also look at all the big randomized controlled cholesterol-lowering trials. This is graphing the progression of atherosclerosis versus LDL cholesterol. More cholesterol, more atherosclerosis; but if you draw a line down through the points, you can estimate that the LDL level at which there is zero progression is down around an LDL cholesterol of 70. You can do the same with the studies preventing heart attacks. Zero coronary heart disease events might be reached down around 55, and those who’ve already had a heart attack and are trying to prevent a second one might need to push their LDL levels even lower.

Atherosclerosis is endemic in our population in part because the average person’s LDL level is up around 130, approximately twice the normal physiologic level. The reason the federal government doesn’t recommend everyone doesn’t shoot for even just under 100, is that despite the lower risk accompanying more optimal cholesterol levels, the intensity of clinical intervention required to achieve such levels for everyone in the population would financially overload the health care system. Drug usage would rise enormously. But they’re assuming drugs are the only way to get our LDL that low. But those eating really plant-based diets may hit the optimal cholesterol target without even trying. Just naturally nailing under 70.

The reason given by the federal government for not advocating what the science shows is best was that it might frustrate the public, who would have difficulty maintaining a lower level, but maybe the public’s greatest frustration would come from not being informed of the optimal diet for health.

To see any graphs, charts, graphics, images, and quotes to which Dr. Greger may be referring, watch the above video. This is just an approximation of the audio contributed by Katie Schloer.

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• National Cholesterol Education Program Expert Panel. Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel III). Circulation. 2002; 106: 3143.
• M M Benjamin, W C Roberts. Facts and principles learned at the 39th Annual Williamsburg Conference on Heart Disease. Proc (Bayl Univ Med Cent). 2013 Apr; 26(2): 124–136.
• J H O’Keefe Jr, L Cordain, W H Harris, R M Moe, R Vogel. Optimal low-density lipoprotein is 50 to 70 mg/dl: lower is better and physiologically normal. J Am Coll Cardiol. 2004 Jun 2;43(11):2142-6.
• C B Esselstyn. Introduction: more than coronary artery disease. The American Journal of Cardiology November 26, 1998. Volume 82, Issue 10, Supplement 2, Pages 5–9.
• W C Roberts. Twenty questions on atherosclerosis. Proc (Bayl Univ Med Cent). 2000 Apr; 13(2): 139–143.
• W C Roberts. Atherosclerotic risk factors--are there ten or is there only one? Am J Cardiol. 1989 Sep 1;64(8):552-4.
• D Steinberg. Thematic review series: the pathogenesis of atherosclerosis: an interpretive history of the cholesterol controversy, part III: mechanistically defining the role of hyperlipidemia. J Lipid Res. 2005 Oct;46(10):2037-51.
• D Steinberg. Thematic review series: the pathogenesis of atherosclerosis. An interpretive history of the cholesterol controversy, part V: the discovery of the statins and the end of the controversy. J Lipid Res. 2006 Jul;47(7):1339-51.
• B McManus. INTERHEART: nine factors that could save your life. Healthc Q. 2005;8(1):28.
• S G De Biase, S F Fernandes, R J Gianini, J L Duarte. Vegetarian diet and cholesterol and triglycerides levels. Arq Bras Cardiol. 2007 Jan;88(1):35-9.

Images thanks to ToM and itsokstay_calm via Flickr.