There has been much debate about optimal cholesterol levels. On the one side there those who say cholesterol does not matter and one should include inflammation along with the importance of cholesterol and other markers. And then there are those who only target the cholesterol. Like most things that are debated in medicine the reality is somewhere in between. I believe the moderate view is the correct one. All factors must be considered especially advanced serum biomarkers such as lipoprotein a, C-reactive protein, PLA2, and homocystine to name a few. I do not think there is any debate on diet lifestyle, though conventional providers do not talk about this and typically provide statin prescriptions that may or may not target a given LDL level. The guidelines changed to targeting certain levels based on risk to prescribing certain doses based on risk. Recently they changed back again to some degree targeting LDL levels. Statins have been popular but now even more so it is the primary therapy.
The Role LDL Cholesterol Plays
After 20 years I can tell you that cholesterol does matter, both HDL and LDL, and triglycerides are all individual risk factors. I have monitored patients who have made almost no changes to diet, lifestyle and supplementation and only by treating cholesterol I have seen plaque progress. This is not a typical scenario for me but I have seen it.
The bottom line is that LDL particles will sneak through the inner lining of an artery and lead to atherosclerosis. If there are small particles this happens faster. In addition if there is oxidative stress, nutritional deficiencies, high blood pressure and other risk factors the plaque deposition accelerates. Cholesterol is not the only component of an atherosclerotic plaque but it is a significant one.
Optimal LDL Target
I read an article that takes a holistic view of human physiology in evolution. It mentions an important factor that targeting LDL alone is approximately 25 percent of the treatment. Also average levels now are for the bulk of human evolution. After the agricultural revolution, higher calorie foods were reduced and less work was required to obtain them. Hunter gathers had LDL levels of approximately 15-75. As a comparison, primates have LDL levels between 40 and 80 and of all the mammals humans have the highest LDL levels. So a cardiologist is not wrong to say that an optimal LDL level is 70 or even lower.
What’s of omission though is that targeting LDL alone is often the only treatment. Also treating it with statins can worsen heart muscle function especially with congestive heart failure, cause liver enzyme elevations, weaken tendons leading to tendon rupture, and cause muscle pain. All of this should make one pause.
The Naturopathic Approach to Treating Cholesterol
A much better initial approach is clearly detailed dietary advice and lifestyle modification which includes stress reduction, exercise, and proper sleep. I target LDL based on risk. A patient who is 40 years old with no visible plaque does not get treated aggressively by me. Conversely a 70-year-old who had a heart attack already and demonstrates growing plaque would be treated aggressively. If we cannot reach target levels with treatment such as niacin, red yeast rice, inositol, green tea, fish oil, increased fiber in the diet, Plant sterols and other such treatments I like to add a prescription. My favorite one to start with is Zetia. Generic name for this is Ezetimibe. Statins are also effective and I typically like to use Crestor because we have seen more incidence of tendon rupture and muscle cramps with Lipitor. Other statins can also be effective.
There is a very long list of well-done studies that show that patients treated further LDL have a lower rate of disease progression. Remember, however, that there is only an approximately 25 percent risk reduction with this treatment.