The Inigo Montoya Guide to Cholesterol

Anyone who grew up during the 80’s has probably seen the movie A Princess Bride.  It’s a charming slanted fairy tale about a farm boy who gets kidnapped by pirates, only to comeback and save his childhood love from an evil king.

The movie has lots of great characters but my favorite has always been Inigo Montoya.  He’s a charming but  often drunk fencer who’s on a lifelong quest to avenge the death of his father.  He eventually teams up with the movie’s protagonist Westley to save princess Buttercup.

One of the most notable scenes from the movie is when Inigo is with his crime boss Ned Vizzini.

He’s a diminutive, annoying little turd who constantly shouts “Inconceivable!” every time an unexpected event happens.

Eventually Inigo retorts to his boss:

You keep using that word.  I do not think it means what you think it means.

We could all take a cue from Mr. Montoya.   Without realizing it we often sling terms and concepts around while losing track of what we’re trying to say on a conceptual level.

This happens all the time in the field of health and nutrition, but never as frequently as when it comes to our cholesterol.

It can be too high or too low.  We have the good and the bad.  But when you understand what these concepts actually refer to, we’re often brought back to the words of Inigo Montoya.

It does not mean what we think it means.

So here’s a handy reference guide to understanding what your doctor’s actually trying to say.

Cholesterol

Contrary to popular perception, there is only one form of cholesterol.  (This is actually technically not true, but will do for the purposes of our discussion).  There is no good or bad kind. Cholesterol is cholesterol.  And if our cholesterol levels didn’t shoot up when we had heart attacks, it’d be regarded as a nutritional rockstar.  It’s as essential a nutrient as essential could possibly be.  It’s used to build cell walls and is the precursor for many of our hormones and vitamin D, among other things.  All animals need copious amounts of cholesterol to survive.

Cholesterol is made in the liver and transported through your blood stream to get to the different tissues where it’s needed.  The problem is that cholesterol is a fatty molecule and your blood is water based, so the two don’t mix very well.  To transport cholesterol throughout your body requires different compounds to shuttle it back and forth.

This leads to a very common confusion in nomenclature.

HDL & LDL – ie, “Good” and “Bad” Cholesterol

LDL is a protein that transports cholesterol into your tissues.  HDL is a protein that transports cholesterol away from your tissues and back to your liver.  They shuttle cholesterol around your body, but are not the same as cholesterol itself!

The reason LDL cholesterol is coined the “bad” kind is because under the Standard American Diet your body loses its ability to take in LDL cholesterol particles out of the blood and they become deposited into the lining of your arteries, which leads to high blood pressure, heart disease, and all that other nasty stuff we’ve heard so much about.

Likewise, HDL particles act like dump trucks, just hauling the cholesterol away from your tissues so it can be recycled.

Cholesterol Levels

When your doctor gives you your cholesterol level, he’s referring to the total amount of cholesterol particles floating around in the cholesterol carrying vesicles in your blood.  HDL, LDL, and everything in between.  (Your body has five molecules total that could conceivably transport cholesterol throughout your body).

Your LDL cholesterol level refers to the number of cholesterol particles being hauled around in its LDL taxicabs, and your HDL cholesterol works the same way.

It’s very much true that high LDL cholesterol levels are a good predictor of heart disease in most people, but looking at examples when this isn’t true causes you to re-think what is causing what.

I don’t think it’s uniformly true that cholesterol is the cause of all heart disease.  It IS true that the Standard American Diet makes it difficult for the body to process the cholesterol that it has, and so slashing cholesterol levels is the low hanging pharmaceutical fruit that drug companies go after.  

It’s also psychologically pleasing to reduce complex situations to a single variable, so a blunt “low cholesterol at all costs” party line is easily digested by the technorati and layperson.  And if you’re a pharmaceutical company, it’s an all-too enticing nail to pound.

Where There’s Confusion

The problems with using cholesterol measurements as a cause for heart disease are two-fold:

• Inflammation might be what causes LDL cholesterol to be dangerous in the first place.  Cholesterol gets oxidized easily, and when this happens your body can’t recognize it anymore and thinks it’s a pathogen.  This is when it gets deposited into your arteries, because it’s no longer recognized by its LDL receptors.    It’s an uncontroversial fact that a lack of sleep, inert lifestyle, chronic stress, and bad diet create a persistently high baseline level of inflammation within the body which causes tissue breakdown and free radical scavenging.  Which results in your body not knowing how to communicate with itself, which means it can’t do all too important stuff like recognize the LDL particles floating around in its blood, among other things.  Seen in this light, a high LDL cholesterol level might be a symptom of a greater underlying problem, and not the root cause of poor heart health itself.
• There are two dimensions to your cholesterol levels.  The total amount of cholesterol residing in your body is what’s usually measured.  An equally important number is the measure of cholesterol carrying particles within your blood, regardless of how much cholesterol you have.  Remember, it’s when the cholesterol transporters can’t get scooped up anymore that the trouble starts, so the more of them you have the more trouble that might be lurking around the corner.  These two figures go hand in hand, so it can be difficult to disentangle which one causes what.  But when the two go in different directions the results are often eye-popping.

When Things Get Screwy

Conventional wisdom begins to lose its cache when you study groups of people that have high amounts of cholesterol but low levels of cholesterol particles, and vice versa.

Chris Kresser covers this topic extremely well, and so does Axel Sigurdsson.   I’ll summarize their points this way:

• In some cases your number of LDL cholesterol particles is a stronger marker than your total cholesterol levels themselves for risk of disease
• People with high LDL-P (particles) and low LDL-C (cholesterol) are often more at risk than people with the opposite profile
• Statins — the most popular cholesterol lowering drug and de facto method for treating people at risk of heart disease — act on your body’s ability to reduce the amount of cholesterol in your body, but do not affect cholesterol particle size.  Thus they might not be the ideal treatment for many people, despite the American Heart Association telling us we all need to take one.
• Low cholesterol levels are often a bigger problem than high cholesterol levels for many populations.

To add another twist to the plot, low-carb high fat diets and high-carb low fat diets affect your cholesterol profile in opposite ways.  Plant based, vegan-ish diets are good for lowering your cholesterol but don’t seem to affect the cholesterol particle number or particle consistency very much.

High fat low-carb diets on the other hand do the exact opposite.  They don’t seem to do all that much for your cholesterol levels, but they do seem to alter the consistency and number of LDL particles floating around in your blood.

We can add this to the mounting pile of evidence that most people probably require an individualized, evidence based approach towards choosing the diet that’s best for them.