Cholesterol might not be the villain we've been told it is

For decades, cholesterol has been considered one of the great evils of the dietary world. It's a major factor in heart disease, we were told, and the higher your levels, the higher your risk. So eat the egg whites but throw out that cholesterol-laden yolk, and don't you dare go near that lobster or shrimp unless you want to turn your arteries into little cement-filled tubes.

But with the Dietary Guidelines Advisory Committee's declaration that cholesterol is "not considered a nutrient of concern for over-consumption," that advice might be thrown in the garbage itself.

The statement worked its way into a December draft report issued by the committee, which provides recommendations for the federal Dietary Guidelines for Americans that are issued jointly by the secretaries of the U.S. Department of Health and Human Services and the U.S. Department of Agriculture and updated every five years.

The final 2015 report hasn't been issued yet — it's expected to be released in a few weeks — but even the advisory committee's preliminary statement might be enough to make even the most health-conscientious Americans throw their hands up in frustration. The last time the guidelines were updated in 2010, they considered consuming less dietary cholesterol a "major goal" for Americans, and advised less than 300 mg per day (an egg has about 186 mg).

So why the turnaround?

Recent (and not-so-recent) medical research. Studies are showing that cholesterol might not be the culprit we've been told it was for the past 40 years. For instance, a national study issued in 2009 by UCLA found that nearly 75 percent of patients hospitalized by a heart attack had cholesterol levels "that would indicate they were not at high risk for a cardiovascular event," and close to half had LDL ("bad" cholesterol) levels classified as "optimal."

One article, published in 2010 in Current Atherosclerosis Reports, noted that recent studies documented the "lack of effect of dietary cholesterol on [cardiovascular heart disease] risk, suggesting that guidelines for dietary cholesterol should be revisited." Another study, published in 2013, "suggests that egg consumption is not associated with the risk of CVD and cardiac mortality in the general population."

Jennifer Haythe, M.D., assistant professor of medicine in the Division of Cardiology, Center for Advanced Cardiac Care at Columbia University Medical Center, said that this research is showing that "maybe cholesterol isn't the bad guy."

Nate E. Lebowitz, M.D., a cardiologist with the Advanced Cardiology Institute at Hackensack University Medical Center Cardiovascular Partners Plus, said cholesterol itself doesn't cause disease — after all, our livers produce about 75 percent of the cholesterol in our bodies, and we need that waxy, fat-like substance because it helps our bodies make vitamin D, hormones and the substances that help digest foods.

What actually creates problems for the heart are the lipoproteins, which are the particles that shuttle cholesterol through the bloodstream, Lebowitz said. For many years, though, there wasn't a good way to break down lipoprotein counts in the doctor's office, and so the cholesterol test was used as a sort of general indicator. This led to the concept of "good" cholesterol (high-density lipoproteins, or HDL) and "bad" cholesterol (low-density lipoproteins, or LDL), and the utterly simplified story that went something like this: LDL particles collect in the arteries, and HDL particles "scrub" them off. So you want more HDL cholesterol because it keeps your arteries clear, and the better your ratio of HDL-to-LDL is, the safer you are.

But, Lebowitz said, the standard cholesterol blood test was "a very poor attempt" to represent what was going on, because there's actually different types of LDL particles — the small, dense kind that worm their way into artery walls and cause plaque buildup, and the larger, less dangerous types that are less likely to do that.

So even though higher LDL numbers aren't particularly good — the more total LDL floating around, the higher the likelihood that some will be the more threatening type — treatment should depend on what type of particle is present, he said.

For instance, two brothers could have the exact same LDL count, Lebowitz said, but depending on the type of LDL particle, one could be at "incredibly high-risk" while the other, not so much — but on the old test, you'd never know which brother had which type. Newer tests are now readily available, however, and they'll break down what types of lipoprotein particles are present, leading to more individualized treatment, he said.

Jeffrey Matican, M.D., chief of cardiology and medical staff president at Englewood Hospital and Medical Center, added that overall cholesterol counts are the "least important" of the numbers given to patients, and traditional factors like age, weight, or an individual's history of smoking or diabetes, as well as the type of LDLs present, are better for assessing risk.

"There's a disconnect quite often — someone can have very good LDL cholesterol, but their particle numbers are very high, and they have a lot of small, dense particles ... And I've had people with reasonably high LDL cholesterol, but their lipoprotein particles are very low. And those people you don't really have to treat, because the things that are invading the [artery] walls are the lipoprotein particles — not the cholesterol."

So is it time to change your diet once more?

First, understand that your genes play a much greater role in your cholesterol level than your diet.

"Whether what you're eating actually changes the blood concentration [of cholesterol] seems to be what's called into question here," Haythe said. "It may be more genetically geared."

"I don't think that dietary cholesterol is much of an issue at all," said Lebowitz with the Advanced Cardiology Institute at Hackensack University Medical Center. Genetics, he said, are a better predictor of cholesterol levels than how many eggs one has for breakfast.

So, if you've been avoiding eggs and shrimp like the plague for heart health, then yes, you can relax on that (unless you're diabetic, in which case experts advise to keep avoiding cholesterol). But, like every dietary dictum, this one comes with the caveat that moderation is best, because overindulging in high-cholesterol foods carries its own risks. You may be hypersensitive to dietary cholesterol (which means that what you eat actually does affect the cholesterol levels in your blood), and many high-cholesterol foods like steak, cheese, onion rings, and ice cream, are also loaded with saturated fat — still (as of now) a dietary no-no.

And the real villains — experts say — are simple carbohydrates like sugar, white bread, pasta and corn syrup, which, they note, while low in cholesterol and fat, have led to increases in obesity, diabetes, and blood pressure, and cause inflammation in the arteries.

Matican said that those who eat a low-carbohydrate diet will likely have less to worry about than those who eat a higher-carbohydrate diet.

Dr. Roger Blumenthal, director of the Johns Hopkins Ciccarone Center for the Prevention of Heart Disease and co-chairman of the American College of Cardiology/American Heart Association Prevention Guidelines Committee, said that the best advice is the same advice that doctors and nutritionists have been repeating for generations: Eat a well-balanced diet heavy on fruits, vegetables, whole grains, and the monounsaturated and polyunsaturated fats found in things like fish, nuts and olive oil, while limiting red meat, fried foods and sugary desserts.

"A vegetarian diet is best, but probably not practical for most Americans," Blumenthal said. "But doing things in moderation — that's more practical."

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