The “cholesterol kills” narrative is a much more complex issue than you might be aware of. There are two very opposing and convincing views as to whether cholesterol does, in fact, cause heart disease or not. Scientists on both sides of the spectrum do have a lot of scientific evidence to back them up, but there are still many questions and uncertainties when it comes to this topic.

Let me introduce you to both sides of the argument starting with why we don’t have to worry so much about cholesterol and, why, on the contrary, it actually could be crucial for good health.

Dr Joseph Mercola, American Physician believes cholesterol is critical for good health. He states the exact opposite of what we have believed for so many years: if blood cholesterol levels are too low, your heart, hormones and cell signalling pathways will suffer and your disease risk will increase (Mercola, 2019). He refers to a very recent study, done in 2019, which shows that if your LDL (yes, the ‘bad’ cholesterol) is too low, you will be at a higher risk for stroke. This impressive study included 96,043 participants and was conducted over a period of around one decade. What they found was that there was a higher risk of stroke when LDL levels were below 70mg/dL, but there was no significant association when LDL levels were more than 70mg/dL (Chaoran, 2019). This research was published in the American Journal of Neurology, which is known as one of the most widely read and highly cited peer-reviewed neurology journals.

But still, the heart and stroke foundation (Health Foundation, 2020) states that “a low LDL level is considered good for your heart health” and that, ideally, your LDL levels should be less than 3 mmol/L, which translates to around 55 mg/dL (Heart Foundation; 2020).

Similar conclusions were made about the benefit of cholesterol when researchers did a longevity study (Ravnskov, 2016). This study included 68 094 elderly participants and it showed that low LDL cholesterol levels were linked to higher mortality rates (once again the exact opposite of the cholesterol hypothesis). The study concludes with the following statement: “Since elderly people with high LDL-C live as long or longer than those with low LDL-C, our analysis provides reason to question the validity of the cholesterol hypothesis.” (Ravnskov, 2016).

The question begging to be asked is how the cholesterol hypothesis was put together in the first place. Dr Reinier van Tonder, an internist focusing on non-invasive cardiology at the Montana hospital in Pretoria as well as Professor Frederick Raal from the University of Witwatersrand (Director of the Carbohydrate & Lipid Metabolism Research Unit) told me a completely different story. Raal’s research shows that “the link between cholesterol and coronary artery disease is one of the most thoroughly researched and established facts in all of medicine” (Raal, 2008). His research further concludes that “most publications that question the causal effect of LDL on the development of ASCVD (cardiovascular disease) tend to cite evidence from individual studies or a small group of highly selected studies, often without a quantitative synthesis of the presented evidence” (Ference et al, 2017).

The researchers further mention that their evidence includes over 2 million participants, 200 studies and they are, therefore, certain that cholesterol, and especially LDL (low-density lipoprotein), causes heart disease. They find that statins are the answer to this dilemma. In their research, they show that statin treatment was associated with a 22% reduced risk of major cardiovascular events “per millimole per litre reduction in LDLC”(Bruckert, E., et al, 2017).

I did notice, however, that the above-mentioned study was funded by the National & British Heart Foundation, among others. This makes me refer back to Tim Noakes’ research. Yes, Tim Noakes has been shunned for some of the advice he has given the public (and was eventually found innocent), but in his new book, The Eat Right Revolution he makes an interesting observation. He and many other researchers call this the ‘biggest medical scam in history”. What does he mean?

Noakes and Marika Sboros write about this in detail, but the crux of the matter is that the American Heart Association still recommends that only 5 or 6 % of our diet should be made up of saturated fats as they believe that it will cause stroke, hearts attacks and cardiovascular disease. According to Sboros and Noakes (2021), there isn’t scientific evidence to back that up. They refer to one of the latest studies to contradict these guidelines. In August 2020, an article, named “Saturated Fats and Health: A Reassessment and Proposal for Food-Based Recommendations” was published in the Journal of the American College of Cardiology. Three former members of the previous Dietary Guidelines Advisory Committees as well as the chair of this committee from 2005, form part of the list of authors. This study concludes that limiting saturated fat, suggested in our dietary guidelines, is ‘without robust evidence’ and ‘arbitrary’. Noakes and Sboros conclude that “industry and financial means might have played a more important role than sound nutrition and the health of the population does” (Noakes & Sboros, 2021).

In their new book, Noakes and Sboros (2021) show that carbohydrates and insulin resistance are the real culprits when it comes to heart disease and not saturated fats. Their research shows that “high-carbohydrate diets increase the number of small, dense LDL-C particles that are particularly prone to oxidation and are positively linked to insulin resistance and increased CHD risk.” They further state that “low-carbohydrate diets can reduce hepatic triglyceride content within days” and proves to be much more effective than low-fat or low-calorie diets. “All damaging metabolic effects caused by insulin resistance” can be reversed by a low-carbohydrate diet” (Noakes & Sboros, 2021).

The excess glucose in the body gets converted into triglyceride which then gets stored in the liver. It then gets exported as lipoproteins or in particular very low-density lipoprotein-cholesterol. This means that dietary carbohydrates and sugars are converted to fats/ triglycerides, which is the really ‘bad’ cholesterol. (Noakes & Sboros, 2021). Chapter 9 in Noakes’s book was written specifically for medical professionals who are critical of this view (Noakes & Sboros, 2021).

Dr Mark Hyman (2016) is also convinced that dietary cholesterol and fat are not the culprits, but rather that it’s refined carbs and sugar that contribute to heart disease and diabesity. Sugar converts to belly fat as well as abnormal blood cholesterol levels.

What about Statins?

It’s interesting to note that statins are still the main line of treatment for cholesterol even though many studies have shown that they might be harmful. I stumbled upon an article published by Harvard Health Medical School on “Managing Statin Muscle Pains”. Instead of encouraging readers to explore dietary solutions to decrease blood cholesterol levels they rather give them tips on how to live with the side effects of statins (Harvard Health, 2017).

Professor Raal (2008) states in his research that he has treated patients with hypercholesterolaemia for many years and that after he has “seen the remarkable benefits of statin therapy, [he has] a low threshold to treat patients with these remarkable, and remarkably safe drugs.”

Many studies do, however, point out some negative side effects. One such study (Kim, 2018) showed that intensive statin use is “significantly associated with an increase in fasting glucose of non-diabetic individuals”. It was published in the Cardiovascular Diabetology and included 379,865 non-diabetic participants. Dr Beatrice Golomb, a professor of medicine from the University of California also did fascinating research on this topic and states that your brain and the neurological system gets affected by statin use (Golomb, 2016). Interestingly, she also did a study that included 250 000 cases in Sweden, where she shows the connection between cholesterol levels and local criminal cases and shows that “people with lower cholesterol at baseline were significantly more likely to be arrested for violent crimes.” You can read more about her take on statins and cholesterol in an article published by the BBC, called The Medications who change who we are (Gorvett, 2020).

What should we do to keep our hearts healthy?  

Yes, it’s complicated! With an overload of information and two very opposing views on this, it’s difficult to know what to do or whom to believe. Here are a few pointers, however, which might be helpful as a starting point:

  • Eat real, whole foods and stay away from processed foods.
  • According to Ian Craig, exercise physiologist, nutritional therapist and editor of the UK nutrition magazine Functional Sports Nutrition we need both fats and carbohydrates as part of our diet. The amount of carbohydrates and fat you can tolerate depends on a wide variety of factors, so be mindful of how your body reacts and adapt accordingly.
  • Prevent insulin resistance and diabetes (and, therefore, heart disease) by removing refined carbs and sugars from your diet and by following a low-carb high-fat eating regime. (Noakes & Sboros, 2021)
  • Include more healthy fats into your diet, but be mindful of the sources of your fat intake to avoid heavy toxicity. Healthy fats include coconut oil, avocado, extra-virgin olive oil, seeds, nuts & wild-caught fish and have been proven to improve the quantity and type of cholesterol in your body (Hyman, 2016). Avoid man-made trans-fats, such as vegetable oils, margarine and emulsified oils as much as possible and choose free-range, hormone-free sources of animal products as far as possible.
  • If you do choose to go with the low-carb approach do make sure to eat enough fibre. This is because fibre is a prebiotic which is vital to our flora/ microbiome. If the microbiome is diverse and gut membranes are healthy, we tend to have good health with a reduced risk for inflammatory disorders.

Resource List:

Bruckert, E., et al (2017) Low-density lipoproteins cause atherosclerotic cardiovascular disease. 1. Evidence from genetic, epidemiologic, and clinical studies. A consensus statement from the European Athero… European Heart Journal (2017) 0, 1–14, doi:10.1093/eurheartj/ehx144

Chaoran, MA et al, 2019. Low-density lipoprotein cholesterol and risk of intracerebral hemorrhage, A prospective study, Neurology Jul 2019, 93 (5) e445-e457; DOI: 10.1212/WNL.0000000000007853

Ference, BA. Et al. 2017. Low-density lipoproteins cause atherosclerotic cardiovascular disease. 1. Evidence from genetic, epidemiologic, and clinical studies. A consensus statement from the European Atherosclerosis Society Consensus Panel. European Heart Journal (2017) 0, 1–14 doi:10.1093/eurheartj/ehx144

Gorvett, Z, 2020, The Medications that change who we are, BBC,

Harvard Health, 2017. Managing Satin Muscle Pain,

Heart Foundation, 2020. Cholesterol,

Heart Foundation. 2020. Eating Guidelines,

Hyman, M. (2016) 7 Ways to optimize cholesterol,

Golomb, BA, 2016. Do Statins Produce Neurological Effects? Scientific American Mind. 27, 4, 72 (July 2016) doi:10.1038/scientificamericanmind0716-72a

Kim, J., Lee, H.S. & Lee, KY. 2018. Effect of statins on fasting glucose in non-diabetic individuals: nationwide population-based health examination in Korea. Cardiovasc Diabetol 17, 155 (2018).

Kolwicz, S.C., & Tian, R (2011) Glucose metabolism and cardiac hypertrophy, Cardiovascular Research, 2011 May 1; 90(2): 194–201.

Mercola, J. 2019. Higher Cholesterol is Associated with longer life,

Noakes, T. & Sboros, M, 2021. The Eat Right Revolution, Your Guide to Living a longer, healthier life, Penguin Random House, Cape Town.

Raal. FJ. 2008. Questioning the importance of LDL cholesterol: don’t throw the baby out with the bathwater! CARDIOVASCULAR JOURNAL OF AFRICA Vol 19, No. 2, March/April 2008, pg 63-64.

Ravnskov U, Diamond DM, Hama R, et al. 2016. Lack of an association or an inverse association between low-density-lipoprotein cholesterol and mortality in the elderly: a systematic review. BMJ Open 2016;6:e010401. doi: 10.1136/bmjopen-2015-010401

Van Bilsen, M., et al (2009) Metabolic remodelling of the failing heart: beneficial or detrimental? Cardiovascular Research, 009 Feb 15;81(3):420-8. doi: 10.1093/cvr/cvn282.

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