The message from the majority of family physicians in Canada that "if you have high cholesterol you should take a Statin medication to lower it” is out of date and not in line with the most recent scientific evidence. Unfortunately, the latest scientific findings take an average of 17 years to reach primary care doctors or even a cardiologist.
When considering high cholesterol from a functional medicine perspective, there are three elements to examine including the underlying causes, what cholesterol markers to study and what are the most significant risk factors.
In this article, we will discuss a functional medicine, evidence-based, approach to high cholesterol including; the six underlying causes of high cholesterol; what are the most accurate predictors of cardiovascular risk; and other crucial cardiovascular risk markers.
The Six Underlying Causes Of High Cholesterol (Hypercholesterolemia)
The functional medicine approach to dealing with this issue is very different from the conventional medicine approach because, in functional medicine, we view high cholesterol not as a disease but as a symptom. We want to know the cause of a symptom. In this regard six main underlying processes can lead to hypercholesterolemia:
There are, of course, other reasons, but these are the six leading causes of high cholesterol that we look for in functional medicine.
A functional medicine practitioner explores all of these factors to determine and address whatever the underlying or root pathology is because if you treat the root, that will often fix the symptoms. If you think of the disease process as a tree, the roots are the underlying mechanisms that lead to the symptoms, which in this analogy are the branches. You can concentrate on the branches and try to deal with things on that level, which is the conventional approach, or you can try to address the roots of the problem, which is what we’re doing in functional medicine.
In conventional medicine, it is a lot more about symptom suppression. If you have high cholesterol, you take a drug to lower it, a statin drug in this case. If you have high blood pressure, you need a prescription medication to diminish that, and it is the same for many other conditions.
Some people have a genetic predisposition to high cholesterol which is known as familial hypercholesterolemia (FH). However, this does not mean that other factors are not also playing a role. Many people with FH also have reduced thyroid function, SIBO and gut dysbiosis, maybe a latent chronic infection and heavy metal toxicity. All of those factors are triggering the genetic predisposition to high cholesterol.
What Markers Are The Most Accurate Predictors Of Cardiovascular Risk
When your family doctor talks about cholesterol, they are talking about total cholesterol, LDL cholesterol, and HDL cholesterol. These markers, however, are not the most accurate predictors of cardiovascular risk. Recent research has shown that these markers, including total and LDL cholesterol, are not strongly associated with heart disease. Your doctor will also usually measure the ratio of total-to-HDL cholesterol as well as non-HDL cholesterol. These markers are better predictors than total cholesterol or LDL cholesterol. However, they are nowhere near as predictive as some of the newer indicators such as LDL particle number. LDL particle size tells us something different than the standard lipid markers.
So why is measuring particle size better? To help explain we will use an analogy. Imagine that your bloodstream is a highway, the lipoproteins are the cars and cholesterol are the passengers inside the cars. If you have a lot of cars on the road, then there is a much higher likelihood of an accident where they might hit the barrier on the side. The barrier of the highway represents the delicate lining of the artery, the endothelium. If you have a lot of LDL particles, which is reflected in the LDL particle size number, then there is a much higher likelihood that one of these LDL particles is going to damage the fragile endothelium.
Another more predictive marker is Lipoprotein(a)(Lp(a)). Lp(a) is known as one of the most damaging lipoproteins, and for this reason, it is currently the single most significant lipid risk marker for heart disease. Of all of the markers, we could measure regarding lipid markers, Lp(a) is the most predictive for future risk of heart disease.
Other Important Cardiovascular Risk Markers
Lipid markers, even particle size and Lp(a), are only one part of the puzzle when it comes to assessing the overall risk of heart disease. We also need to look at things like family history, inflammatory markers like C-reactive protein, fibrinogen, Lp-PLA2, oxidised LDL, and metabolic markers like fasting insulin, fasting glucose, fasting leptin, post-meal blood sugar, and haemoglobin A1c.
Hypertension and smoking are two of the most influential risk factors for heart disease.
Diet, lifestyle, stress, and nutritional status are significant. Nutritional status includes not enough of nutrients like vitamin D but also too much of a nutrient like iron which increases the risk of heart disease.
There is an increasing amount of research that shows that the microbiota plays a significant role in heart disease pathogenesis.
Heart Disease Risk Calculators
There are some risk calculators available for free online that use at least a small number of these risk factors. The Reynolds Risk Score, for example, uses C-reactive protein, and systolic blood pressure in addition to age, total cholesterol, HDL cholesterol, and family history to determine the 10-year risk of heart disease expressed as a percentage. You enter all of your information in, and it calculates a proportion of the chance you have for having a heart attack in the next ten years based on all of these validated criteria. The lowest it could be is 1 per cent, and then it goes up from there. You can put different numbers in and see which factor has the most significant impact on risk. You will notice it is not total cholesterol or even HDL cholesterol, but age is the most significant risk factor for heart disease.
There are other types of lab testing that look for objective evidence of plaque accumulation, like a calcium score and carotid intima-media thickness (CIMT). These are tests that your doctor can do, and they provide a different perspective on risk. The lipid markers are indicators that are typically associated with heart disease, but a calcium score and CIMT test can show what is happening regarding plaque accumulation.
If you have high cholesterol and would like to see if a Functional Medicine approach might help you, you can find your nearest practitioner by going to the Institute of Functional Medicine website.
