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Cholesterol Myths

“So, my cholesterol’s running high?  It’s probably all those eggs I’m eating.  Give me a couple of months and I can fix that with my diet.  I don’t want a heart attack… but I also don’t want to be on one of those statin drugs.  Who wants something that saves your heart but then wrecks your liver?

Those are the kinds of statements I hear day in and day out in my practice.  They express several of the myths that are rampant about cholesterol.  In fact cholesterol has recently been in the news because the government’s Dietary Guidelines Advisory Committee is reportedly going to remove their longstanding recommendation to restrict cholesterol in the diet.

The wheels of science often grind very slowly and sometimes get stuck in a misguided rut for long stretches.  One of those ruts has been the idea that cholesterol in the diet, such as is contained in the yolk of an egg, needs to be carefully limited in order to protect one’s heart health.  It seemed to make sense since cholesterol is found in some of the plaque that blocks arteries and leads to heart attack and stroke.  But over the years the evidence for the evils of dietary cholesterol has simply not shown up.  In fact, as heretical as this may at first sound, a lot of folks with the very common pre-diabetic metabolic syndrome would do better having an egg and a little cheese for breakfast rather than a bowl of oatmeal.

Even after decades of study, we are far from figuring out all that there is to know about cholesterol and cardiovascular health.  But if we can’t give all the answers, let’s at least explode a few myths.  Besides the one noted above about the assumed dangers of dietary cholesterol, here are three more:

  • Myth #1: High cholesterol is mostly due to a bad diet and can be readily fixed by adjusting your diet.  Reality: For most people cholesterol is about 80% genetics and 20% lifestyle.  So it can certainly be improved with a healthy lifestyle, but there is a large part of it over which we have little control.  It’s still good to work at the 20%, but it’s not a simple fix.
  • Myth #2: Anyone with high cholesterol is at risk and would probably benefit from a statin drug.  Reality: These cholesterol-lowering medicines do work very well to lower cholesterol.  However, the main place that they have shown a reduction in events (such as heart attacks) is in folks with known heart disease, or (less so) in those with very high risk factors for heart disease.  Some folks with high cholesterol are actually at very low risk for heart disease and stroke.  That’s why in trying to better answer whether one of our high cholesterol patients should consider a statin, we employ tests such as the coronary calcium scores and/or a specialized arterial ultrasound called a carotid intimal medial thickness test.  These are non-invasive and affordable tests which help us sort our high cholesterol patients into those who are clearly plaque-formers and those who don’t seem to be.  We then recommend consideration of a statin, as well as other aggressive preventive measures only for the plaque-formers.
  • Myth #3: Cholesterol-lowering statin drugs are quite dangerous and can wreck your liver. Reality: Although, as noted above, they are certainly not needed by everyone with high cholesterol, they have been quite thoroughly tested and their side-effects are well-known and manageable.  For example, there is no statistical increase in liver failure among those on statin drugs vs. those not taking a statin.  However they do bump blood sugar up mildly and probably around 15% of folks get muscle aches that cause us to switch brands or take them off statins entirely.  So statins are neither the big answer nor the big villain; they’re just another tool.

We could go on, but you get the idea. As with most things, reality is a little more complicated than the myths.  It is often said that half of what we put forth as medical truth is false… and the trouble is we don’t know which half is which.  It should keep us humble, but it shouldn’t make us despair.  After all, for about 1900 years after Christ, the average life-span was stuck at about 38 years (partly because of the high number of infant and childhood deaths) whereas we’re at more than double that now.  Over time, if we follow the evidence and resist impatiently grabbing the newest too-good-to-be-true fix-all promises, we do arrive at some helpful realities.  In cholesterol management as with the rest of life, hang in there and keep holding out for the true and the good.

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