A Holistic Approach to High Cholesterol
Being diagnosed with high cholesterol isn’t a position anyone wants to be in, especially if you’re left feeling disempowered with limited choices to manage it. Fortunately, naturopaths have many tools in our toolkit when it comes to balancing your cholesterol levels and reducing your overall cardiovascular risk. As you’ll learn, the topic of cholesterol isn’t as straightforward as once thought and embracing a more holistic approach will empower you to be an active participant in your health journey.
Your body needs cholesterol
Cholesterol isn’t inherently harmful. It plays a vital role in the production of hormones like oestrogen, progesterone, testosterone & cortisol, as well as bile acids to digest fat & absorb fat-soluble vitamins. It’s also important for cell membranes, neurotransmitter function and vitamin D production. Most of your cholesterol is made by your liver, but some is found in food. Cholesterol doesn't dissolve well in your blood (think oil mixing with water), so it has to be carried by vehicles called lipoproteins. You may be familiar with the two main lipoproteins LDL "bad cholesterol" and HDL "good cholesterol," but we also have others such as VLDL, IDL, and Lp(a).
Cholesterol is just one piece of the puzzle
High cholesterol, or more specifically elevated total and LDL cholesterol are known risk factors for heart disease. This is because they play a role in the formation of plaque in the arteries, known as atherosclerosis. However, as research evolves, we’re beginning to learn that it’s a bit more complex than this. Even though statins (a drug that blocks cholesterol production in the liver) are the world’s most prescribed medication, heart disease remains the leading cause of death worldwide. About 50% of people with cardiovascular disease have normal LDL levels [1]. On the flip side, not everyone with high cholesterol will go on to develop cardiovascular disease [6]. Rather than getting caught up in a single number, we should pay attention to the broader spectrum of factors contributing to heart health.
These factors include:
LDL Particle size - Not all LDL is created equal. Some are small and dense, and others are large and fluffy. It’s the small particles that are most associated with heart disease, rather than larger ones [1]. A standard test measures the overall amount of cholesterol being carried by LDL, rather than particle size. Diet, lifestyle & certain supplements can influence particle size.
HDL quality - Similarly, not all HDL is the same. A recent study found that elevated HDL cholesterol levels had no significant protection against coronary artery calcification [11]. This isn’t to say HDL isn’t protective, but it’s more about the quality and functionality of your HDL which isn’t measured in a blood test. Diet can improve HDL quality [12].
Apob levels - The ApoB test is becoming recognised as a better predictor of cardiovascular disease risk than the traditional total cholesterol, LDL-c & HDL-c test. This is because it can identify elevated numbers of small, atherogenic particles [2].
Lipoprotein(a) - One in five people carry the Lp(a) gene which causes up to a 70% greater risk of cardiovascular events throughout their lifetime [3]. Not routinely tested for but an important test if you are concerned about your heart disease risk. There is no current conventional treatment, but those with elevated Lp(a) should reduce as many other risk factors as possible.
Coronary Calcium Score: An important non-invasive test for assessing plaque build-up in the arteries. It’s useful for reclassifying your cardiovascular risk if you have high cholesterol and determining if statins aren’t necessary [6]. Request this test from your doctor if they are concerned about your cholesterol levels.
Familial hypercholesterolemia (FH): FH is an inherited genetic condition that leads to extremely high levels of LDL-c from birth. It’s associated with a 50% risk of heart attack or stroke by the age of 50, and often requires statins. It’s important to distinguish between true FH and other causes of high cholesterol. Genetic testing is the gold standard for diagnosing FH.
Triglycerides and insulin: Elevated triglycerides and insulin resistance are a major cause of predominantly small LDL particles regardless of cholesterol levels. Fasting triglycerides above 2.8mmol/l may be predictive of elevated small LDL & levels under 0.8 may predict predominantly larger LDL [4].
Inflammation: High sensitivity C-reactive protein (hsCRP) is a marker of inflammation in the body. Elevated hsCRP levels are associated with an increased risk of heart disease because chronic low-grade inflammation is a hallmark of atherosclerosis [5].
High blood pressure: High blood pressure is a significant risk factor for heart disease as it places stress on the artery walls and makes them more susceptible to cholesterol deposition. It also contributes to inflammation and oxidative stress, and makes established plaques more likely to rupture, leading to clots/heart attack.
Homocysteine: Homocysteine is an amino acid in the blood associated with an increased risk of heart disease. It does this by damaging blood vessels, promoting inflammation and oxidative stress, as well as promoting blood clot formation. Homocysteine levels in the blood can be influenced by genetic variations, in particular the MTHFR gene variant. Treatment involves supplementing with specific B vitamins.
Diet & lifestyle are key
The most well-researched diet for cardiovascular disease prevention is by far the Mediterranean diet. It’s been shown to reduce many of the above risk factors including inflammation, high blood pressure, insulin resistance, elevated triglycerides and ApoB, as well as reduce smaller LDL particles and improve HDL quality [12, 16]. It has also been shown to reduce cardiovascular risk in those diagnosed with familial hypercholesterolemia [15].
If you’re not sure where to begin, simply just reduce your intake of processed and packaged foods in favour of natural whole foods. Eat more fruit and veg, wholegrains and legumes, as well as plenty of heart-healthy fats like extra virgin olive oil, avocado, nuts, seeds and oily fish. Eat less pre-packaged meals and snacks, especially those high in sugar and refined carbs like white flour. You’ll also want to avoid processed meats, trans fats and high-sodium foods.
Aside from diet, it’s also important to make sure you’re exercising at least 20-40 minutes a day, as well as prioritising getting 8 hours of quality sleep a night and managing stress. It’s also crucial to avoid smoking and vaping, and limit alcohol as much as possible.
Helpful Interventions
There are many natural supplements that are effective at helping manage cholesterol, however, It’s important to get professional guidance.
Bergamot - Has been shown to significantly lower total cholesterol, LDL and triglycerides and increase HDL [7]. Contains antioxidants that prevent the oxidation of LDL cholesterol and promote larger, less harmful LDL molecules. Also helps with insulin resistance.
Vitamin E Tocotrienols - Tocotrienols are a specific form of vitamin E that inhibit HMG-CoA reductase to lower cholesterol & ApoB levels [8]. They also lower triglycerides, protect LDL from oxidation, and exert anti-inflammatory properties.
Red Yeast Rice - Red yeast rice is known as one of the most effective natural cholesterol-lowering supplements. It contains a compound called monacolin A that has been shown to reduce LDL levels by 15% and 25% within 6 to 8 weeks. It has been shown to also reduce total cholesterol, ApoB and CRP [9].
Ubiquinol - Ubiquinol is the active form of CoQ10, an antioxidant enzyme in your body that plays a particularly important role in heart health. It provides energy to your heart muscle, helps to protect blood vessels, reduces inflammation and lowers blood pressure. CoQ10 is also important for preventing the oxidation of LDL cholesterol, and a deficiency can increase the risk of heart disease [10]. Ironically, statins inhibit CoQ10 production in the liver, so it’s recommended that everyone on statins supplement with ubiquinol.
Vitamin K2 - Vitamin K2 protects your arteries from calcification (plaque build-up) by directing calcium to your bones and teeth instead. It also promotes the production of nitric oxide, a molecule that relaxes blood vessels and promotes healthy blood flow. Ironically statins also inhibit the production of vitamin K2, so supplementation is recommended [10].
Specifically for Lp(a) reduction - Whilst there are currently no known treatments for lowering Lp(a) levels, Dr Ross Walker, a well-regarded integrative cardiologist, uses a combination of vitamin C, vitamin E, lysine and vitamin B3.
Remember that cholesterol is only one piece of the puzzle, so it’s important to also investigate and treat those other risk factors - triglycerides, insulin resistance, inflammation, homocysteine and blood pressure. These have their own individual interventions which is why it’s important to get individualised advice from a practitioner.
Helpful Tests
For a thorough assessment of your cholesterol: ask your doctor for a lipid panel (total cholesterol, LDL, HDL & triglycerides) plus ApoB and Lp(a).
If your doctor is concerned about elevated cholesterol - request a coronary calcium score.
Testing oxidised LDL, HDL & LDL subfractions can also be helpful in some cases.
For a holistic assessment of your overall cardiovascular health: test fasting glucose and insulin, hsCRP, homocysteine & thyroid panel (TSH, T4 & T3).
There is also such thing as too little cholesterol
The cholesterol lab reference ranges are based solely on heart disease prevention without factoring in how cholesterol levels affect other systems of the body. There is no discussion about what is too low and the impact that too little cholesterol has on mental health, cognitive decline, hormone production, immunity and cancer risk. In a study conducted on 12.8 million people, those with total cholesterol levels under 200mg/dl or 5.17mmol/L had the highest mortality rates [15]. This is something to watch out for if you have gut issues, hyperthyroidism or are vegan (increasing plant sources of saturated fats can help).
How can a naturopath help
Having the support of a naturopath can help you navigate the complexities of cholesterol and cardiovascular health and make sure you’re on the right path. We can offer professional guidance, a holistic assessment of your cardiovascular risk, appropriate testing and interpretation, as well as an individualised treatment plan to target the underlying drivers.
If cholesterol is a concern for you and you’d love my help, please get in touch.
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