We have got cholesterol completely wrong

Here are six things that we need to know about cholesterol:

i)    It is virtually impossible to explain how vital cholesterol is to the human body. If you had no cholesterol in your body you would be dead. No cells, no bone structure, no muscles, no hormones, no sex, no reproductive system, no digestion, no brain function, no memory, no nerve endings, no movement, no human life – nothing without cholesterol. It is utterly vital and we die instantly without it.

ii)    Cholesterol is so vital to the body that our bodies make it. The body cannot risk leaving it to chance that we would get it externally from food or some other external factor – that’s how critical it is.

iii) There is no such thing as good cholesterol and bad cholesterol. Cholesterol is cholesterol. The chemical formula for cholesterol is C27H46O. There is no good version or bad version of this formula.HDL is not even cholesterol, let alone good. LDL is not even cholesterol, let alone bad. HDL stands for High Density Lipoprotein. LDL stands for Low Density Lipoprotein. (There are three other lipoproteins, by the way, chylomicrons, VLDL and IDL).

Fat and cholesterol are not water soluble so they need to be carried around the body in something to do their vital work. The carriers of such substances are called lipoproteins. We can think of lipoproteins as tiny ‘taxi cabs’ travelling round the blood stream acting as transporters. So, lipoproteins are carriers of cholesterol – oh – and triglyceride and phospholipids and protein. All lipoproteins carry all of these substances – just in different proportions. LDL would more accurately be called the carrier of fresh cholesterol and HDL would more accurately be called the carrier of recycled cholesterol.

iv)    The standard blood cholesterol test does not measure LDL  – it estimates it. The fasting blood cholesterol test can only measure total cholesterol and HDL. There are two other unknowns in a four variable equation – LDL and VLDL. The estimation is refined further using the Friedewald equation (named after William Friedewald, who developed it).

Total cholesterol = LDL + HDL + Triglycerides/5 (Ref 1) (More detail here.)

As any mathematician will tell you, one equation, with four variables, only two of which can be measured, is a fat lot of good. We need at least one more equation or known variable, to avoid circular references. This also means that:
–    All other things being equal, LDL will rise if a) total cholesterol rises and/or b) if HDL falls and/or if c) triglycerides fall.
–    All other things being equal, LDL will fall if a) total cholesterol falls and/or b) if HDL rises and/or if c) triglycerides rise.

No wonder an inverse association is observed between LDL and HDL – it is by definition. More surprising is that a fall in triglycerides, which would be welcomed by doctors, would be accompanied by an automatic increase in LDL, all other things being equal, which would not be welcomed by doctors. And you thought that this was scientific.

v)    Statins stop the body from producing the cholesterol that it is designed to produce. They literally stop one of our fundamental body processes from being able to function. The intelligent view on statins is that in the very limited arena where they appear to have some ‘benefit’ (men over 50 who have already had a heart attack), they ‘work’ by having anti-inflammatory properties and that the fact that they lower cholesterol (by stopping the body from being able to produce this vital substance) is a very unfortunate side effect. (Drug companies should work on developing something that has the anti-inflammatory benefit without this huge and damaging side effect – it’s called aspirin).

One in 500 people have familial hypercholesterolemia and may have a problem clearing cholesterol in their body (rather like type 1 diabetics who can’t return their blood glucose levels to normal). For anyone else to be actively trying to lower their vital and life affirming cholesterol levels is deeply troubling.

vi)    “Cholesterol in food has no impact on cholesterol in the blood and we’ve known that all along.” Ancel Keys.

Ancel Keys, the same man who did the brilliant Minnesota starvation experiment, spent the 1950’s trying to show that cholesterol in food was associated with cholesterol in the blood. He concluded unequivocally that there was not even an association, let alone a causation. He never deviated from this view.

Cholesterol is only found in animal foods (it is a vital substance for every living creature). Hence the only foods that Keys could add to human diets, to test the impact of cholesterol, were animal foods. Given that he concluded that eating animal foods had no impact on blood cholesterol levels, it follows that animal foods per se have no impact on blood cholesterol levels (not that high cholesterol is a problem but that’s another story).

There is no need, whatsoever, to avoid liver, red meat, other meat, fish, eggs, dairy products etc for any cholesterol that they may contain.

The body makes cholesterol. I worry about a number of things, but I don’t worry that my body is trying to kill me.

UPDATE: Following numerous blog comments from people “worried about cholesterol”, I’ve written this post.


Ref 1: EH Mangiapane, AM Salter, Diet, Lipoproteins and Coronary Heart Disease: A Biochemical Perspective, Nottingham University Press, (1999). (See reference 159 The Obesity Epidemic)

309 thoughts on “We have got cholesterol completely wrong

  • October 21, 2022 at 9:34 pm

    Just ran across your article on Cholesterol: I am a 71 yr old woman. 5’2″ 113 ls. Have een very physically active ran my 1st marathon at age 60. I’m now reitred and not as active, y choice. I can still run up and downstairs of our 2 story home and keep up with my 20 something gkids. I have always had high (hereditary) cholesterol.
    Total is 254
    HDL is 54
    Trigi s 135
    LDL 173
    Chol/HDLC ratio is 4.7
    and my non HDL is 200.
    I’m sure my dr. wants me on statins, but I resist annually. 11 months ago my ratio was at 5.6 so it adjusts itself currently at 4.7 which is good. And I have not given up anything I desire to eat. Can I yes, will I no. I have always been anemic so probs will start on VitD and and iron supplement. I do take a tsp. of Fish oil daily. Whats your op[inion? Thanks in advance Peggy

  • March 24, 2021 at 7:23 pm

    Zoe. I know this is going to sound simplistic, but sometimes things are simple and people can be stupid, no matter how clever they are…
    Could this whole cholesterol thing be down to the fact when people are in the morgue their cholesterol has gone below body temperature and is solid.

    Then the pathologist says it’s clogged arteries…

    Just a thought

    • March 24, 2021 at 7:56 pm

      Hi Juliet
      And a very interesting one! In the early cholesterol work with the Russian pathologists (early 1900s) this could have been an observation.

      Best wishes – Zoe

  • December 16, 2020 at 12:38 pm

    I have been diagnosed as having fh from the lipid clinic they want me on a statin as they said I will have a heart attack without them colesrtol is 8. 5 I am terrified.

    • December 22, 2020 at 1:52 pm

      Hi Carol
      Ask the lipid clinic to do a proper test for FH (genetic test) as that level of cholesterol is on the normal distribution. Many people with FH have cholesterol in double figures even on statins.

      This may be of interest:

      And talk to your medics about your fears as being scared/anxious/stressed can cause health problems in itself.
      Best wishes Zoe

  • September 26, 2020 at 10:30 pm

    For decades it has been known that CVD is not caused by cholesterol.
    Having low cholesterol does not protect you from CVD.

    They don’t know what causes CVD, but they do know that the mediterranean diet produces much less CVD.
    Eat lots of veggies with lots of extra virgin olive oil and not too much meat.

    The money hungry Big Pharm and not-so-smart doctors are just trying to make money by pushing
    statin drugs that have negative side effects..
    This I have known for decades and the American Heart Association is finally telling the truth about cholesterol. In fact–it is known that for those over 60 years of age, having low cholesterol causes more CVD. The sad thing about this is that doctors are influenced by Big Pharma salesmen who show up at their office with all kinds of mis-information,

    • November 25, 2020 at 1:07 pm

      Statin drugs are one of the most prescribed medications.4 According to a study in JAMA Cardiology, the number of people using statins jumped from 21.8 million in 2002-2003 to 39.2 million in 2012-2013, the most current data available.5 Annual prescriptions rose from 134 million to 221 million during the same time, which represented a 64.9% increase

  • January 27, 2020 at 12:39 pm

    I know u said that a cholesterol of 7 is not high
    And I agree. But how do insurance companies view,it when applying for a death policy ie all
    Life policy

    • January 27, 2020 at 2:01 pm

      Hi Phillip
      Probably as high – unfortunately for them and the policy payer!
      Best wishes – Zoe

  • December 20, 2019 at 1:13 pm

    Hi zoe harcombe
    I’ve just recieved a letter about my cholesterol from the consultant
    In chemical pathology
    Would u like me to send to u a copy vie gmail
    I dont mind if u print it but after reading the great cholesterol con and your pages on cholesterol I would be interested on your feed back. By the way when she saw my cholesterol and drops from 7 to6 and I remarked on it she said it would not come down any lower can that be true

  • December 20, 2019 at 1:07 pm

    Hi zoe harcombe
    I’ve just recieved a letter about my cholesterol from the consultant
    In chemical pathology
    Would u like me to send to u a copy vie gmail
    I dont mind if u print it but after reading the great cholesterol con and your pages on cholesterol I would be interested on your feed back.

  • December 19, 2019 at 12:52 pm

    Hi zoe
    When u say cholesterol is c27 h46 0
    If there were bad cholesterol would there be another chemical value added on to the formular ie like H2 0 +salt if water was salty

    • December 20, 2019 at 3:40 pm

      Hi Phillip
      Kind of. The cholesterol is cholesterol is C27H46O is the key point. The water analogy is a bit different. Water is H2O and it can have a nasty chemical in it and thus be ‘bad water’ but it’s not really – it’s still water (H2O) plus something nasty. ‘Bad’ cholesterol isn’t even cholesterol pus something – which would be cholestero + something bad. They call cholesterol bad when it’s in one ‘taxi’ ( LDL) and good when it’s in another (HDL). That takes dull to a whole new level!
      Best wishes – Zoe

  • December 19, 2019 at 8:31 am

    When to drs yesterday about cholesterol
    Quoted some of the stuff u have written
    Canot get her to agree about cholesterol
    And how the older u get the high the cholesterol level is better the lower mortality
    She would not gave it and she is supposed to be a specialist she offered me statin which I refused why carnt they see the light. I just think they go along with the rest

  • November 18, 2019 at 12:27 am

    I have an 86/yo father who is suffering from many of the adverse affects that, as you say, crept up, killing one cell at a time!!
    I MEAN LIFE THREATENING. As I do not know if he is in Renal Failure, Heart Failure, some MCI (mild cognitive impair’t., be we rescued with Coconut oil. AND – how convenient that after 10 yrs. of Zocor, simvastatin, the patient is now “old”, and the MD can, AND HAS SAID, muscle wasting is due to aging.

    I have SO MANY Alternatives to step-in and alleviate any cardio-vascular disease that my father may have. Since he did have a stent put in when in mid-to late 70 yrs. So many natural remedies from garlic, pomegranate, to Co-Enzyme Q10, MAGNESIUM ACTS AS A NATURAL STATINS, to artichoke extract to = ALL WITH EXTENSIVE STUDIES to show how much BETTER and effective than STATINS. NATURAL REMEDIES TO KEEP INFLAMMATION DOWN = OMEGA-3’s, to CURCUMIN.
    D3/K2 – TO PREVENT CALCIFICATION. Other minerals to quell the nasty, NUCLEAR FACTOR KAPPA-B.
    B-Complex vitamins to maintain electrical pulse rate, blood pressure, vaso-dialating.
    Bring down CRP and Homocysteine with various natural enzymes, minerals, etc. NATTO – stop fibrins and clots forming.
    Clove and oregano oil to keep PATHOGENS or what is now called NANO-BACTERIA that want to nestle into the Endothelium, and then attract CALCIUM as a Shell to Cover them. VITAMIN C TO PREVENT CRACKS IN THE ENDOTHELIUM….
    All good stuff, but wait: I JUST DO NOT SEE ANYTHING ABOUT SAFELY TAPERING OFF, other than slowly lowering dosage??
    Any view on this, anyone. Thanks much.

  • November 11, 2019 at 9:36 am

    Hi zoe if high cholesterol is not bad for people
    Does that include familhypocholstraleme.
    Only I have a score of 7. I am not unduly worried about that, but my gp wants me to attend a lipids clinic. also how can I know if this is the true score it might be lower probley scaremungry to get me back on statin.
    Please reply thanks phill

  • November 4, 2019 at 3:29 pm

    Zoe is cholesterol level of seven in your estimation to high

  • October 21, 2019 at 8:31 am

    Hi, two years ago I was told by my GP I had high cholesterol and needed statins I was prescribed simverstatin within a month I had erectile dis function, never had it previously and after stopping taking them everything returned to normal, I returned to my GP who after hearing my problems then prescribed atorvastatin as it had less side effects, one month in and bang how wrong was he , woke with raging tinnitus, within a week I couldn’t focus my left eye, my speech became slurred, I had memory problems , sharp stabbing pains in the heart area, tingling in my fingers , terrible headaches I felt awful and quite frankly thought it was the end I was unable to participate in exercise ( a regular 4 time a week gym goer previously) eventually I was told the statins had a toxic effect on my nervous system The upshot of all this is it took over two years for my body to return to some sort of normality , I’m left with permanent tinnitus albeit at a lower volume. so my advice is stay away from statins or little pieces of poison as they were once described to me I certainly will be in future

    • October 21, 2019 at 9:08 am

      Hi Dean
      Wow – I’m so sorry to hear what you’ve been through. First do no harm eh? This really is a cautionary story although hopefully a rare one.
      I hope that some of the damage repairs more over time.
      Best wishes – Zoe

  • August 13, 2019 at 4:12 pm

    Hi Zoe. I’m 57, still play sports, not obese and I think have a reasonably healthy lifestyle. I’d been feeling like I had my head stuck in a bucket for a long time. They I started to get dizziness so I went to the doctor where I live in Spain. He ordered a full blood test. Everything came back fine except my overall cholesterol number was 274, my HDL was 42 but my LDL was 191. He said the LDL level was dangerously high and that if a heart specialist saw that they’d immediately put me on the highest level of statins possible. As it is, he’s put me on a low level, but he has told me to stop rigorous exercise and it’s too much of a risk. I can walk and swim but that’s it. I’ve given up alcohol, all dairy products and red meat. Now your article is undermining my trust in my doctors advice. I’m two weeks in to the statins and I feel a lot better. The dizziness has gone, my head feels a lot clearer and generally I feel stronger. I don’t doubt for one second that it’s all about the money, but who to believe…….???

    • August 13, 2019 at 8:21 pm

      Hi Pete

      This is my main post for reading about cholesterol and statins: https://www.zoeharcombe.com/2015/03/worried-about-cholesterol-andor-statins/

      The important thing is that you feel better – but what made the difference, because you changed many things? Giving up alcohol should have made a difference. Stopping rigorous exercise and doing more natural stuff (walk/swim) should have helped. You may have been intolerant to dairy. It’s rare to have an issue with meat – but you may have been eating deli meat in Spain and thus consuming quite a bit of salt? That could have raised your blood pressure and made you feel bad and you now may feel better. You may have had some inflammation, which the statins may have helped with. What I doubt is that the cholesterol lowering effect of statins makes you feel better, because this is not something that the body feels within a couple of weeks.

      Always work with your doc to do what’s right for you.
      Best wishes – Zoe

  • June 23, 2019 at 4:42 pm

    Thank you for great articles which I have studied! I am 63, healthy and fit (I run 12 -15km 3x a week. Before Keto my cholesterol was 7 ( I brought it down to 4.1 by high doses of niacin 3x a day. NOT going to do that for ever!) After 2 yrs of keto and one yr of almost carnivore I recently went for blood work and shocked the living daylights out of my GP The trig/HDL ratio is under 1 but the total cholesterol is 18.
    It really shook me because I feel so great and I DO understand the cholesterol story so I was not worried at all. Question: can severe stress do this to my cholesterol? (My healthy, fit 29yr old son ran a race 9 months ago and then dropped dead. My husband just wants to die and I have to lift him up but I dont always feel like it since I am also grieving and then I feel so guilty! My husband just landed in ICU because basically his whole body is packing up. I have never experienced such a thing. That’s when I had the blood work done since I spent my days at the hospital anyway) I am estrogen dominant. Can that make such a big difference? If I really have a total cholesterol of 18 would that be of concern because I cannot remove it? I will never take statins.

    Please help me because my GP is insisting that I see a cardiologist and I do not mind because I would like to know the state of my veins. (I know it will be good) but I would prefer a banting cardiologist but I cant find such a doctor!

    Thank you for being a beacon of reason in such a messed up society.


  • May 31, 2019 at 9:35 am

    Take 4 cloves of crushed Garlic in one cup of milk & one cup of water. Then, boil the mix until its volume becomes one cup. This preparation is known as Lahsun-Ksheer-Paak. Filter it and have one cup every morning on an empty stomach.
    Try this home remedy to balance or low cholesterol level.

  • April 29, 2019 at 5:38 pm


    I’ve been told I need to go on statins because of high cholesterol levels, high LDL and high total. How do I tell my doctor that I don’t want to go on them and here’s why? Changing doctors doesn’t help as they all say the same thing.

    • April 29, 2019 at 6:02 pm

      Hi William
      I’m not sure if this is an upside or downside of paying for your own healthcare. In the UK, where meds are free, people can say no. The docs may not like it, but there are no health insurance repercussions because most people don’t have health insurance – they have the National Health Service.

      In the US, I hear more often that it’s a health insurance issue and your premium is higher if your cholesterol is higher – madness. It should be the other way round, but hey ho. (https://www.zoeharcombe.com/2010/11/cholesterol-heart-disease-there-is-a-relationship-but-its-not-what-you-think/)

      If you’ve over 70, the patient leaflet is on your side, as it cautions against over 70s taking them (because high cholesterol is especially associated with lower death rates in the elderly). You could take plant sterols (from any pharmacy or health food shop). They will lower cholesterol but increase your risk of heart disease and cancer. (https://thescipub.com/abstract/10.3844/ojbsci.2014.167.169). So, not a good idea, but may keep your doc off your back. Or you could check out Dave Feldman’s work – he suggests a way to lower cholesterol with diet – you could try this and then do it before a doc visit if you wanted to.

      Here’s more info – for you or your doc: https://www.zoeharcombe.com/2015/03/worried-about-cholesterol-andor-statins/

      Best wishes – Zoe

  • April 9, 2019 at 1:25 am

    Found this researching my high cholesterol (284 total, ldl 211). I wasn’t overly concerned other than wondering about inflammation in my body. However, my hdl was 63 in in the past and over 210 this time! Is that bad?

    • April 9, 2019 at 8:35 am

      Hi Dee
      You may find this post interesting: https://www.zoeharcombe.com/2015/03/worried-about-cholesterol-andor-statins/

      Do you mean your LDL was 63 in the past and over 210 this time? You can’t have both LDL and HDL over 210 and a total cholesterol of 284…

      If you are based in the northern hemisphere, you probably haven’t sunbathed for months and therefore your cholesterol will be higher than at the end of the summer months. You may have an illness or injury (or even stress) that your body is trying to repair – hence making more cholesterol. I don’t know your age – there are established associations with high cholesterol and low mortality (read that carefully) in older people especially.

      Best wishes – Zoe

  • April 5, 2019 at 12:16 pm

    Hello Dr Harcombe

    I’m 67 and had a NHS Health Check in the summer of 2018, they said my total cholesterol was 6.1 (high?). I then spent 4 winter months in SE Asia on a totally different diet of fish, rice, exotic fruits and leaf veg. When I returned to the UK I requested a further measurement and the NHS came back with a total cholesterol measurement of 4.2, a “substantial reduction” my doctor declared.
    My question, is this believable? To my engineering brain it seems like a massive reduction and I immediately question the measurement accuracy.
    I would be very interested in your comments, please.

    • April 5, 2019 at 5:13 pm

      Hi Michael

      I’m a research doctor, not a medical doctor so I can give info and opinions…
      Some interesting info is that the test is 19% inaccurate before you factor in anything else e.g. what you ate the day before the test, stress levels on the day, running late for the appointment etc (https://www.bmj.com/content/298/6689/1659)

      Another thought is – did you get sunshine in the winter away?! Cholesterol is turned into vit D with sunshine – that’s why cholesterol levels are lower after time in warmer climates.

      You may have been consuming plant foods that contain plant sterols, which could lower your cholesterol (but increase your risk of bad health outcomes) https://thescipub.com/abstract/10.3844/ojbsci.2014.167.169

      A few thoughts!
      Best wishes – Zoe

  • April 4, 2019 at 12:17 pm

    Thanks for sharing the info. my high LDL and HDL always freaks me out, a total cholesterol of around 7.2mmol/l of LDL around 4.5mmol/l. Even if I am exercise in the gym at least 1 hour daily, having a high dietary fiber and all most no red meat diet. My triglyceride level is very low in the body though.
    Lately I found out when I exercise less for 6 months, my cholesterol level gone down to 6.8mmol/l…. Just doesn’t make sense at all….

  • March 11, 2019 at 8:32 pm

    Dear Doctor, you are a refreshing voice of reason and common sense in a drug fuelled world! Your concise description of what cholesterol actually is and does for us humans is spot on! I couldn’t have written it better myself. Yes, LDL transports cholesterol through the blood stream so it can get to all our cells which keep us alive. However, the public remain confused and worried because they refuse to educate themselves. This basic information should be taught in every junior school – it will never happen unfortunately, as Big Pharma would step in!

  • March 10, 2019 at 7:23 am

    I am 34 years old men normal weight not smoking not drinking alcohol at all BP is normal my LDL is 4.2 mmol and doctors told me I need statins. I am scared. I just feel normal I am active in my life. Last year LDL was 4.7 mmol. I don’t know what to do :(

  • March 2, 2019 at 7:13 am

    Dr. Zoe,
    You are phenomenal. It’s not only “we got cholesterol all wrong” but you got it all right!
    My question is about the cholesterol in animal products. Why it has no impact to the blood cholesterol and where is it transmitted after being digested. How does it affect the body. Thanks

    • March 2, 2019 at 7:34 am

      Thanks Anthony – you have no idea how timely your comment is! The body makes cholesterol – if we consume cholesterol, the body doesn’t need to make as much, but it has been shown to be virtually impossible to eat enough cholesterol to provide more than the body would make anyway (people have tried it with tens of eggs a day, for example). I see it as giving your body a bit less to do!
      Best wishes – Zoe

  • February 19, 2019 at 4:21 pm

    What about non-alcoholic fatty liver disease (NAFLD)?
    NAFLD is now the most common cause of chronic liver disease in the United States, affecting 70 million Americans, nearly one in three adults.

    It’s been characterized as a tale of fat and sugar, but evidently not all types of fat are culpable. Those with fatty hepatitis were found to have eaten more animal fat and cholesterol, and less plant fat, fiber, and antioxidants. This may explain why adherence to a Mediterranean-style diet, characterized by high consumption of foods such as fruits, vegetables, whole grains, and beans, is associated with less severe non-alcoholic fatty liver disease. It could also be related to the presence of specific phytonutrients, like the purple, red, and blue anthocyanin pigments found in berries, grapes, plums, red cabbage, red onions, and radicchio. These anthocyanin-rich foods may be promising for the prevention of fatty liver, but that’s mostly based on petri dish experiments. There was one clinical trial that found that drinking a purple sweet potato beverage seemed to successfully dampen liver inflammation.

    A more plant-based diet may also improve our microbiome, the good bacteria in our gut. “‘We are what we eat’ is the old adage but the modern version might be ‘we are what our bacteria eat.’” When we eat fat, we may facilitate the growth of bad bacteria, which can release inflammatory molecules that increase the leakiness of our gut and contribute to fatty liver disease.

    Fatty liver disease can also be caused by cholesterol overload. The thought is that dietary cholesterol found in eggs, meat, and dairy oxidizes and then upregulates liver X receptor alpha, which can upregulate something else called SREBP, which can increase the level of fat in the liver. Cholesterol crystals alone cause human white blood cells to spill out inflammatory compounds, just like uric acid crystals in gout. That’s what may be triggering the progression of fatty liver into serious hepatitis: “the accumulation of sufficient concentrations of free cholesterol within steatotic hepatocytes [fatty liver cells] to cause crystallization of the cholesterol.” This is one of several recent lines of evidence suggesting that dietary cholesterol plays an important role in the development of fatty hepatitis—that is, fatty liver inflammation.

    In a study of 9,000 American adults followed for 13 years, researchers found a strong association between dietary cholesterol intake and hospitalization and death from cirrhosis and liver cancer, as dietary cholesterol can oxidize and cause toxic and carcinogenic effects. To limit the toxicity of excess cholesterol derived from the diet, the liver tries to rid itself of cholesterol by dumping it into the bloodstream. So, by measuring the non-HDL cholesterol in the blood, one can predict the onset of fatty liver disease. If we subtract HDL from total cholesterol, none of the hundreds of subjects followed with a value under 130 developed the disease. Drug companies view non-alcoholic fatty liver disease as a bonanza, “as is the case of any disease of affluence…considering its already high and rising prevalence and…[its] needing continuous pharmacologic treatment,” but maybe avoiding it is as easy as changing our diet, avoiding sugary and cholesterol-laden foods.

  • February 19, 2019 at 4:08 pm

    What is the evidence that “elevated cholesterol” causes atherosclerosis? There are 4 supporting arguments in my view.4–7 (1) Atherosclerotic plaques are easily produced experimentally in herbivores (e.g., rabbits, monkeys) simply by feeding these animals cholesterol (e.g., egg yolks) or saturated fats. Indeed, atherosclerosis is probably the second easiest disease to produce experimentally. (The first is an endocrine deficiency—simply excise an endocrine gland.) (2) Cholesterol is present in atherosclerotic plaques in ex- perimentally produced atherosclerosis and in plaques in human beings. (3) Societies and subjects with high serum cholesterol levels (total and low-density lipoprotein [LDL] cholesterol) compared to populations and subjects with low levels have a high frequency of atherosclerotic events, a high frequency of dying from these events, and a large quantity (burden) of plaque in their arteries. Lowering total and LDL cholesterol levels decrease the frequency of atherosclerotic events, the chances of dying from these events, and the quantity of plaques in the arteries. No one has produced atherosclerosis experimentally by increasing arterial blood pressure or glu- cose levels or by blowing smoke in the faces of rabbits their entire lifetime or by stressing these animals. The only way to produce atherosclerosis experimentally is by feeding high-cholesterol and/or high–saturated fat diets to herbi- vores. (Atherosclerosis is not a disease of carnivores and it is not possible to produce atherosclerosis in carnivores [dogs, cats, tigers, lions, etc.] unless the thyroid gland is removed or made dysfunctional before a high-cholesterol or high–saturated fat diet is administered.11)
    Why has the proved causal relation between abnormal serum LDL cholesterol and atherosclerosis been so difficult to accept by so many extremely intelligent physicians? One factor, in my view, is that this cholesterol–atherosclerosis causal relation has been diluted by the concept of multiple atherosclerotic risk factors and the idea that atherosclerosis is a multifactorial disease. The Framingham study, which has taught us all so much, introduced the concept of “risk factors” and fostered the view that the larger the number of risk factors present, the greater the chance of atherosclerotic events.12 As a consequence, increased cholesterol became just 1 of several risk factors and was perceived as essentiallymg/dl, the patient whose systolic systemic blood pressure is 170 mm Hg versus the other patient with a systolic pressure of 115 mm Hg is at much greater risk of an atherosclerotic event. Cigarette smoking may work in similar fashion. Nev- ertheless, if serum LDL cholesterol is 60 mg/dl, maybe 50 mg/dl, irrespective of degree of blood pressure in- crease or number of cigarettes smoked daily, atherosclerotic plaques do not develop.
    Another factor may be the use of multiple atherosclerotic risk factors in guidelines for who to treat and who not to treat with lipid-lowering drugs. Although guidelines do fo- cus on serum LDL cholesterol level, the number of other risk factors present play a prominent role in this therapeutic decision.19 If no other nonlipid risk factors are present or only if 1 non-LDL cholesterol risk factor is present and there have been no previous atherosclerotic events and di- abetes mellitus is not present, the magical drug treatment number is an LDL cholesterol 190 mg/dl. Refraining from drug intervention until this very high LDL cholesterol level is reached plays down or even nullifies the importance of cholesterol in preventing events. (It is important to realize that the lipid-lowering drug guidelines [1988, 1993, 2001, and 2004] have to do only with decreasing atherosclerotic events. They do not concern themselves with preventing atherosclerotic plaques in the first place. Of course, if atherosclerotic plaques are prevented, atherosclerotic events do not occur!)

    It is time to move on from a goal “to decrease risk” to a goal “to prevent plaques.”21 To do so requires much lower levels of LDL cholesterol than advocated by guideline pub- lications. My goal for all subjects worldwide is a serum LDL cholesterol 100 mg/dl and ideally 60 mg/dl. The beauty of the Justification for Use of Statins in Prevention: an Intervention Trial Evaluating Rosuvastatin (JUPITER) is that it dramatically demonstrates what incredible decreases in events can be produced in a short period (2 years) by decreasing LDL cholesterol by 50% even when starting from a level considered by many to be normal (130 mg). The mean level (108 mg/dl) might be considered “good” or even “great” by many physicians but its lowering to 55mg/dl (by rosuvastatin 20 mg/dl) decreased all events by 40%, indeed nearly 50%, including a decrease in stroke by 48%! This trial beautifully shows that we can drastically decrease or even prevent atherosclerotic events and expensive procedures by taking a single pill every day and do it safely. Most Americans will not reach JUPITER treatment levels (LDL cholesterol 55 mg/dl) by diet alone.
    The lower the LDL cholesterol, the better, and this prin- ciple has been established repeatedly despite voices of the anticholesterol, antistatin fallacy mongers! It’s the cholesterol, stupid!
    From the Editor 1365

    William Clifford Roberts, MD
    Baylor Heart and Vascular Institute Baylor University Medical Center Dallas, Texas
    Green LA. Cholesterol-lowering therapy for primary prevention: still much we don’t know. Arch Intern Med 2010;170:1007–1008.
    Ray KK, Seshasai SR, Erqou S, Sever P, Jukema JW, Ford I, Sattar N. Statins and all-cause mortality in high-risk primary prevention: a meta-analysis of 11 randomized controlled trials involving 65,229 participants. Arch Intern Med 2010;170:1024–1031.
    de Lorgeril M, Salen P, Abramson J, Dodin S, Hamazaki T, Kostucki W, Okuyama H, Pavy B, Rabaeus M. Cholesterol lowering, cardio- vascular diseases, and the rosuvastatin–JUPITER controversy: a crit- ical reappraisal. Arch Intern Med 2010;170:1032–1036.
    Roberts WC. Atherosclerotic risk factors: are there ten or is there only one? Am J Cardiol 1989;64:552–554.
    Roberts WC. Atherosclerosis: its cause and its prevention. Am J Cardiol 2006;98:1550 –1555.
    Steinberg D. The Cholesterol Wars. The Skeptics vs. the Preponder- ance of Evidence. Amsterdam: Elsevier, 2007:227.
    Truswell AS. Cholesterol and Beyond. The Research on Diet and Coronary Heart Disease 1900–2000. Sydney: Springer, 2010:227.e principle, however, does not apply to cholesterol. Patients with the highest serum levels of total and LDL cholesterol, namely those patients with homozy- gous familial hypercholesterolemia, have an incredibly high frequency of atherosclerotic events and they have these events at very young ages—teenage years.18 In addition, patients with the next highest serum LDL cholesterol levels, namely those with heterozygous familial hypercholesterol- emia, have atherosclerotic events often in their 30s and 40s.
    A third factor preventing acceptance of the causal rela- tion between abnormal serum LDL cholesterol and athero- sclerosis has been the observation that of adults with non- familial hypercholesterolemia but similar levels of serum LDL cholesterol, some develop atherosclerotic events and others do not. It is in this group particularly in my view that the other risk factors and high-density lipoprotein choles- terol levels come into play. Of 2 patients of similar age and gender and similar serum LDL cholesterol levels, say 130

  • January 16, 2019 at 4:12 pm

    Dear Dr. Zoe,
    I am a Sri Lankan male, 64 years of age. I have been concerned with this cholesterol thing for the last 30 years or so. But since of late I came to know, by my research on the net that the world bodies such as AHA, USDA and similar institutions in the other leading western countries are not willing to consider the mounting evidence gathered all around the world through multiple researches that that we have missed the point in demonizing the saturated fat and the functions of cholesterol. Today I got my Lipid profile results of 248 total cholesterol, 60.3 HDL, 174.6 LDL and 67.6 triglycerided. Despite the knowledged I have had gained in this matter, I once agains started to worry about LDL and total cholesterol. So, I once again started to google and lo and behold, it is still full of the lastest articles feeding us the same crap food of how bad LDL is and all that. Then I came across your bold article and also your various other related artilces and took heart that I would not worry about this “high” LDL or 174.6 any more, since I have FBS of 93 and no cardio vascular issues ( though I have been on border on my blood pressure, which I carried for a long time and I suppose it was due to my stressfull career in finance and tax. Anyway, thanks for your well reseached articles.

    • January 16, 2019 at 5:39 pm

      Hi Gehan
      Thank you for your kind words.

      Please note that I’m not a medical doctor – I have a research doctorate. I can give information and opinions, but not medical advice…

      You’ve found one of my posts – this is my main post on all things cholesterol and statins (https://www.zoeharcombe.com/2015/03/worried-about-cholesterol-andor-statins/) and do follow the links to other pages and sites, as there’s a lot of information. (And you may like the video recommended at the end from Dr Malcolm Kendrick – his book The Great Cholesterol Con is fabulous.) You may also enjoy the mass of information on wwwdrmalcolmkendrick.org – he has been writing about what really causes heart disease for years.

      Malcolm also collaborated on a paper about LDL being inversely associated with mortality in the elderly (https://bmjopen.bmj.com/content/6/6/e010401). i.e. lower LDL associated with higher deaths. You can see which age groups in the paper, but you won’t be far away from not wanting lower LDL!

      Good luck with your reading
      Best wishes – Zoe

  • December 22, 2018 at 1:53 pm

    Hello Mrs Zoe

    I have a 4 years old daughter with diagnosed familial hypertriglyceridemia, also called FCS, LPL Deficiency, Type 1 hyperlipidemia etc. All MDs recommend completely fat-free diet to prevent pancreatitis. We’re very afraid of her overall health. We’re told this is genetic.

    We do not have family history but my little angel has been syruggling with this condition. I want you to believe me that I sometimes fell desperate completely.

    Any advice would be appreciated.

    • December 22, 2018 at 2:24 pm

      Hi Gokhan
      I’m really sorry but I can’t and don’t give advice – just information and views. I am surprised that a 4 yr old would have had a lipid test. Anyone should be surprised by the diagnosis too, as that’s a 1 in a million condition. If your daughter really does have FCS, your best option would be to find an expert on the condition, as it is so rare, and to hope that they have learned from treating the few others who may have had this.
      Best wishes for your management of this – Zoe

      • December 22, 2018 at 3:10 pm

        Thank you but all experts from all around the world recommend completely fat-free diet. I do not believe this is our only option and the last hope.

        Human metabolism has so many secrets, and we’ll find one of them someday

  • December 18, 2018 at 12:39 am

    My cholesterol is 213 and I was worried I have cholesterol spots on my eyes and a cholesterol granuloma in my petrious Apex bone and my mom is being told cholesterol is crawling up her throat and cutting off her air please help we are also both pre diabetic.

  • November 20, 2018 at 1:35 am

    I am surprised that you reference Ancel Keyes, a man who cherry-picked the seven countries he included in his most famous study because they fit his hypothesis, and buried data from 15 others, because they disproved his theory.

    • November 20, 2018 at 3:21 pm

      Hi Crystal – I referenced Keys because he did some very useful work – including the research to show that cholesterol in food doesn’t impact cholesterol in the blood, as was mentioned in this post.

      You make the common error about Key’s seven countries study and his six countries graph. This may help: https://www.zoeharcombe.com/2017/02/keys-six-countries-graph/

      Best wishes – Zoe

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