421: The Cholesterol Myth & Statin Lies? What you need to know about the latest research on heart health

On Air with Ella podcast episode 421

On Air with Ella 421: The Cholesterol Myth and Statin Lies

This is not medical advice. This is a summary of my research and references, and its accuracy is not at all guaranteed. Do your research, and consult your practitioner.

Debunking Cholesterol Myths: A New Perspective on Heart Health

Cholesterol is part of cell membranes and prompts production of crucial hormones. And it's widely understood that too much can cause problems - namely contributing to clogged arteries and raising the risk of heart problems. When physicians and researchers talk about cholesterol’s harms, they’re usually referring specifically to low-density lipoprotein. LDL transports cholesterol around the body, depositing it in blood vessels. Its cousin, high-density lipoprotein (HDL), has long been thought of as the “good” cholesterol because it typically ferries cholesterol away from other parts of the body to the liver. So, high LDL = "bad" and HDL = "good."

But this is not the whole story.

For decades, cholesterol has been vilified as the primary cause of heart disease. What if cholesterol isn’t the enemy? What if I told you that it’s well established that cholesterol plays a critical role in your immune function, hormone production, and even your longevity?

Emerging research challenges the conventional narrative, and reveals that cholesterol is not just a risk factor, it’s actually an essential component of optimal health.

A recent study published in JAMA Network Open highlights a U-shaped relationship between cholesterol levels and mortality risk - we actually need to find a balance for optimal health - not just aim for rock-bottom numbers.

I researched this episode for my own education, and wanted to share what I learned with you, because so much of what we hear is just flat out wrong or omits many important pieces of information. But remember, I do this research for my benefit and for your entertainment. If you are considering your own health, please do you own research, and work with your health practitioner - I have shared dozens of references throughout this article for you to get started!

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Myth #1: Cholesterol is binary. High LDL is bad. Low HDL is good.

The facts: Cholesterol is essential to the human body. It can also be an indication of risk. Determining the risk is not a linear equation.

For decades, we've been told that cholesterol is a dangerous substance that must be aggressively lowered with statins to prevent heart disease. But what if this widely accepted view is not only incomplete but also fundamentally flawed? A growing number of experts, including cardiologist Dr. Aseem Malhotra, Dr. Peter Attia, and researchers like Dr. Nathalie Pamir, are challenging this traditional approach, urging us to rethink everything we thought we knew about cholesterol, statins, and heart health.

For decades, cholesterol has been vilified as a primary driver of heart disease, with statins prescribed and promoted as a universal solution. Many cardiologists and researchers are challenging this narrative, arguing that our focus on cholesterol is misguided and potentially harmful.

Cholesterol: Unpacking the Complexities

The conventional wisdom simplifies cholesterol into "good" (HDL) and "bad" (LDL), with the primary goal being to lower LDL at all costs. However, this model fails to capture the complex interplay of factors that contribute to cardiovascular health.

A large study published in 2022 by Dr. Nathalie Pamir found that HDL's ("good cholesterol") protective effects vary by race. Specifically, low HDL was associated with increased risk for heart disease among white adults, but not among Black adults, and high HDL was not protective in either group. "The study found that high HDL levels did not provide a protective benefit for Black adults, and even among white adults, high HDL was not significantly associated with fewer coronary heart disease events." - Reference

As Dr. Jeffrey Berger (NYU) explains, while LDL is a key predictor of heart disease, the relationship isn’t straightforward. The real problem isn’t cholesterol itself, but the underlying metabolic conditions - like insulin resistance and inflammation - that influence its impact on our bodies.

Myth 2: Cholesterol Is the Root Cause of Heart Disease

The facts:

Cholesterol is essential for cell repair and hormone production. The simplistic "good vs. bad" cholesterol model (HDL vs. LDL) is outdated and overly simplistic.
LDL cholesterol is not always a reliable predictor of heart disease risk for most people. Studies show high LDL levels don’t consistently correlate with cardiovascular events, especially in older adults.
While high LDL levels can signal risk, they’re not a universal predictor. Dr. Nathalie Pamir’s research reveals that HDL’s protective effects vary by race. This challenges the simplistic "good vs. bad" narrative.
Insulin resistance driven by processed foods and sedentary lifestyles is a critical (and under-acknowledged) metabolic driver of heart disease.

Myth 3: Statins Are a Safe, One-Size-Fits-All Solution

The facts:

Some studies suggest statins may offer a modest survival benefit in primary prevention, particularly for individuals with certain risk factors. However, the benefit may be small and not universally applicable to all populations. The benefits of statins can vary significantly based on individual factors, including age, sex, and overall health status. A study from the University of Oxford suggests that statins may not be beneficial for all:

Observational studies have reported muscle weakness/pain, liver impairment, new-onset diabetes and haemorrhagic stroke15 40 41 but the incidence of these adverse effects has been much lower in clinical trials.42 Importantly, statins may interact with other medications, contributing to adverse drug reactions and avoidable hospitalisations.43 Older adults exposed to polypharmacy are more vulnerable to adverse reactions and increased risks of adverse effects. As with efficacy, the burden of statin adverse effects in older people has not been well studied. As a result, it is still not possible to know the balance of risks and benefits in this age group.44

In conclusion, the gains made in increasing lifespan may not have been accompanied by similar gains in healthy life, for the additional later years of life lived. A strong potential exists for greater use of statins for primary prevention to extend healthy life and maintain independence among the ageing population however, current evidence for starting statins among older people is insufficient to support this approach. The STAtins in Reducing Events in the Elderly (STAREE) trial is a large scale randomised controlled trial (RCT) specifically designed to address this need.individuals over 60, with potential for harm in some cases.

Side Effects Risk: 20–50% of statin users experience side effects (muscle pain, brain fog, erectile dysfunction), yet guidelines rarely emphasize these trade-offs.
Over-use: Statins may benefit high-risk patients (eg, post-heart attack), but they’re overprescribed to low-risk individuals. (For example, one study estimated a 600% increase in eligibility for statins between 1987 and 2016.)

Statins are among the most prescribed drugs globally, but their benefits are often overstated, and risks underplayed. [See article]

The Statin Paradox: Erectile Dysfunction (ED)

Statins have a dual impact on sexual health. While they boost nitric oxide (NO) production - a key mediator of erections - they may also suppress testosterone production by blocking cholesterol synthesis.

Nitric Oxide (NO) Boost: Statins like atorvastatin enhance NO, improving blood flow to the penis.
Hormonal Harm: Long-term use can reduce free testosterone and may cause testicular atrophy.
Mechanistic Conflicts: Statins inhibit the RhoA/Rho-kinase pathway, which aids smooth muscle relaxation in erectile tissue.

The data does not agree on this issue across various studies (linked below), e.g.:

"Conflicting reports exist regarding the role of statins in male gonadal and sexual function. Some studies report a beneficial effect, particularly for erectile dysfunction (ED), through statins’ anti-inflammatory and cardiovascular protective properties. Others suggest that statins might be associated with sexual dysfunction through negative effects on hormone levels." [ref]

Myth 4: Lowering LDL Cholesterol Guarantees Protection

The facts:

Lowering LDL doesn’t address systemic inflammation nor insulin resistance, which are more critical to heart health.
Extremely low LDL levels may weaken immunity and correlate with higher cancer risk.
Dr. Peter Attia argues that LDL particle count (via ApoB testing) is a better risk marker than LDL-C, as it reflects atherogenic particles more accurately.
- ApoB" is pronounced as "AY-poh-BEE". It is a shortened form of "apolipoprotein B," which refers to a protein attached to lipoproteins that are involved in transporting cholesterol and other lipids through the bloodstream. The more you know!...

Inflammation, not Cholesterol, is a cause of chronic disease. [NIH]

Emerging Consensus on Cholesterol and Heart Health

Precision Medicine, Metabolic Health and Advanced Lipidology

The experts I researched advocate for a shift toward precision medicine - tailoring treatments to genetics, lifestyle, and metabolic health - rather than one-size-fits-all statin prescriptions. They challenge statin-centric guidelines, urging a shift toward metabolic optimization and inflammation reduction, and advocate for addressing root causes (e.g., processed diets, sedentary lifestyles) over biomarker manipulation alone.

The future of heart health lies in precision medicine, not one-size-fits-all statin prescriptions.

So, what should we be tracking instead of just those basic cholesterol numbers? The key is to get a more complete picture of your cardiovascular health. This means looking beyond LDL and HDL and considering these key factors:

Triglyceride-to-HDL Ratio: Think of this as a snapshot of your metabolic health.
High-Sensitivity CRP (hs-CRP): This measures inflammation in your body, a major driver of heart disease.
Insulin Resistance and Metabolic Health: In general, you want to learn more about metabolic health. How well does your body process sugar?

These are arguably stronger predictors of cardiovascular risk than cholesterol alone. If you're looking to go even deeper, talk to your doctor about these advanced lipid markers:

ApoB: This measures the actual number of artery-clogging particles in your blood (Dr. Peter Attia considers this superior to just LDL-C).
Cholesterol Efflux Capacity: Measures how well your HDL is actually removing cholesterol, not just the amount of HDL in your blood (Dr. Dan Rader’s research emphasizes this).

These aren't your 'everyday' tests, but talk to your doctor and know that you have other options than "just taking statins."

A comprehensive assessment gives you a much clearer understanding of your true risk.

Metabolic Health is an Under-Considered Culprit

We can impact our heart health through lifestyle and nutrition choices. Focusing on whole foods, regular exercise, stress management, and sleep - not just biomarkers like LDL vs. HDL - can be beneficial.

Prioritize Nutrition: Ultra-processed diets spike insulin, driving obesity, diabetes, and heart disease. Prioritize whole foods (olive oil, nuts, fish) and avoid ultra-processed carbs.
Exercise: Improves insulin sensitivity and reduces inflammation.
Stress Management: Meditation lowers cortisol and studies of meditation suggest a possible benefit on cardiovascular risk.
Sleep: Poor sleep disrupts metabolic health and raises cardiovascular risk.

Lifestyle changes may reduce plaque buildup and improve heart function, offering hope beyond lifelong medication.

The cholesterol-statin narrative is outdated. By prioritizing metabolic health, leveraging advanced lipidology (ApoB, efflux capacity), and challenging commercial bias, we may be able to prevent - and even reverse - heart disease. [ref]

Three Calls to Action to Consider:

1. Educate Yourself: Read the books shared below and/or explore the articles and other resources shared here to explore the evidence for yourself.

2. Advocate for Precision Care: Demand advanced testing (not just LDL-C) and lifestyle-first strategies before pharmaceuticals.

3. Spread Awareness: Share these resources for a more updated, science-backed perspective with others to counter decades of oversimplified commercial messaging.

"The best prescription is not in the pill bottle but on the plate. The future of heart health isn’t about lowering a number - it’s about optimizing the complex interplay of diet, hormones, inflammation, and metabolism." - Dr. Aseem Malhotra

The Cholesterol Myth: Research Cited & Further Reading

Books:

Podcasts:

Medical Studies:

Articles:

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