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How You Should Eat to Lower Cholesterol Is Controversial

An international panel says there's little evidence that LDL cholesterol is an important risk factor for heart disease. A low-fat diet might not be helpful.
How You Should Eat to Lower Cholesterol Is Controversial
Mixed leaf salad with smoked salmon, spinach, cucumber, red onion, herbs and black kumin. Healthy diet. Low carb meal. Copy space

What should you eat to lower cholesterol into an acceptable range? If you have high cholesterol, your doctor has doubtless told you to avoid saturated fat. Those who have high cholesterol running in the family will hear this advice repeatedly. Such individuals are told to shun high-fat dairy products like whole milk, ice cream or butter and stick with a low-fat diet. In particular, their doctors warn them not to eat eggs, because of the cholesterol contained in egg yolk.

Trouble With the Diet-Heart Hypothesis:

Although it is the standard regimen, this low-fat approach has stirred controversy for years. An international group of experts explains that the evidence supporting a low saturated-fat, low cholesterol diet to prevent heart attacks is weak (BMJ Evidence-Based Medicine, July 5, 2020). Such recommendations are based on the “diet-heart hypothesis.”

In the diet-heart hypothesis, eating fat elevates LDL cholesterol and that leads to heart disease. However, this approach is overly simplistic. The authors argue that lowering cholesterol, whether through diet or other means, does not necessarily reduce someone’s chance of a heart attack.

Other Problems Contributing to Heart Disease:

Clinicians may use “bad” LDL cholesterol as the sole marker of risk because it is easy to measure. However, studies don’t show that LDL cholesterol predicts premature death from heart disease. Instead, high-risk individuals should also pay close attention to other factors that may predispose them to heart disease. These include high blood pressure, calcium in their coronary arteries, belly fat and inflammation. You can’t change these by altering what you eat to lower cholesterol.

For certain individuals, the scientists propose, a “risk triad” of high triglycerides, small, dense LDL particles and low levels of HDL cholesterol is linked to a higher risk of heart attacks. In addition, lipoprotein a [Lp(a)] and factors that contribute to blood clot formation help drive heart disease. People who follow a low-carb diet can lower Lp(a), thus reducing their risk of cardiovascular problems. We should not have to say that smokers are at increased risk of heart attacks due to blood clots and have less flexible blood vessels. The first item on any action list should be: Quit smoking!

Disagreement on What to Eat to Lower Cholesterol:

If a low-fat, low-cholesterol diet is not supported by evidence, what should we eat? The scientists offer research showing that many people with familial hypercholesterolemia don’t respond normally to insulin secretion. Doctors sometimes call this condition “metabolic syndrome.” Consequently, these insulin-resistant individuals might do better on a low-carbohydrate diet. Such a regimen could lower triglycerides and Lp(a) and raise HDL cholesterol. That might counteract an increase in LDL cholesterol (British Journal of Nutrition, Feb. 14, 2016). 

In their article in BMJ Evidence-Based Medicine, the scientists call for clinical trials to test that hypothesis. We don’t have sound studies to support any dietary recommendations at this point. As a result, people don’t know how to eat to lower cholesterol and, more importantly, reduce their overall risk for heart disease.

In summary, the researchers call for scientific studies of the effects of a low-carb diet [LCD] on heart disease risk factors in people with familial hypercholesterolemia [FH]:

“There is sufficient rationale for conducting clinical trials to assess the effects of an LCD on FH individuals with an insulin-resistant phenotype.”

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About the Author
Terry Graedon, PhD, is a medical anthropologist and co-host of The People’s Pharmacy radio show, co-author of The People’s Pharmacy syndicated newspaper columns and numerous books, and co-founder of The People’s Pharmacy website. Terry taught in the Duke University School of Nursing and was an adjunct assistant professor in the Department of Anthropology. She is a Fellow of the Society of Applied Anthropology. Terry is one of the country's leading authorities on the science behind folk remedies. .
  • Diamond DM et al, "Dietary recommendations for familial hypercholesterolaemia: an evidence-free zone." BMJ Evidence-Based Medicine, July 5, 2020. http://dx.doi.org/10.1136/bmjebm-2020-111412
  • Mansoor N et al, "Effects of low-carbohydrate diets v. low-fat diets on body weight and cardiovascular risk factors: A meta-analysis of randomised controlled trials." British Journal of Nutrition, Feb. 14, 2016. DOI: 10.1017/S0007114515004699
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