Question: Should I manage my total cholesterol of 305 just for my doctor or should I be doing it for my own sake? If so, how should I do it?

You should want to improve your lipid profile for a lot more than to please your doctor.

Let's revisit this from a cholesterol skeptic point of view. Uffe Ravnskov, he wrote a book called The Cholesterol Myths. In that book, he shows a graph from the Framingham study where he maps out the people who have heart disease and the people who don't. If you look at that graph, one thing that you see is that everyone who had total cholesterol over 300 had heart disease and no one who didn't have heart disease had cholesterol that high.

Look, the only way to have a total cholesterol of 300 or more in most cases is to either have a thyroid disorder or to have a familial hyperlipidemia. We're talking about fasting levels here. You should want to manage your blood lipids for your own sake because people with familial hypercholesterolemia have a dramatically increased risk of having heart disease decades earlier than it becomes normal for the general population. 

I'm not saying it's 100% certain that if you have a cholesterol of 300 you will have heart disease, but you are way disproportionate in risk for that reason. You definitely want to address this for the sake of your health.

I think that if you have weight to lose, that losing weight should be one of the first things that you do to normalize your blood lipids and your inflammation. Being overweight also contributes to elevated free fatty acids, and elevated free fatty acids do raise your blood lipids. That's, in fact, the entire rationale of using high-dose niacin to lower LDL-C is by suppressing free fatty acid release.

It’s also important to address any inflammation in your gut. You might have microbiome issues, and working more high-fiber vegetables into your diet and diversifying across the different plant fibers is a great way to nourish your microbiome, reduce inflammation that comes from the intestines that would negatively affect your blood lipids.

If these things that we just talked about aren't enough to get the blood lipids into the normal range, then I think you want to experiment with eating more carbohydrate and a low-fat diet, but selecting those foods to maintain nutrient density. You could add something like psyllium husk fiber , which might be both good for your gut and the inflammation coming from your gut. It will also help reduce your cholesterol by making bile acids go into your feces and making your liver draw cholesterol from the blood.

If those natural things don't get your blood lipids into the normal range, then I think that you should consider being open to pharmacological methods. I've gone through all the cholesterol-skeptic literature and I'm against demonizing cholesterol. I do not believe that high cholesterol is the cause of heart disease.

But if your lipids are that high, it's overwhelmingly because you are not clearing them from the blood, and not clearing them from the blood is the single most important risk factor for them oxidizing, and them oxidizing does cause heart disease. 

This Q&A can also be found as part of a much longer episode, here: https://chrismasterjohnphd.com/podcast/2019/03/08/ask-anything-nutrition-feb-23-2019

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