Being that September is Cholesterol Education Month, I’d like to set the record straight. Many of my colleagues in the cardiology community would have you believe that the numbers are what matter, and that lower is better. However, it’s a lot more complicated than that.


Firstly, cholesterol is not some fearful villainous substance. It is a waxy substance essential to life. It's the precursor to vitamin D and our sex hormones such as progesterone, estrogen and testosterone. It also has a role in the production of bile acids which aid in the digestion of fats. Moreover, cholesterol is vital for the formation of myelin sheaths that coat and protect our nerve cells (neurons), as well as for the production of new neurons.

Indeed, cholesterol is essential to health. In fact, it’s been shown that a  cholesterol level too low can put your health in jeopardy.

Cholesterol has been studied extensively over the last several years. What makes it so attractive as a risk factor is that we have medications, namely statins, that lower it quite nicely. So with the advent of statins we can lower cholesterol significantly and help reduce the risk of heart disease. 

If only it was that simple!  Did you know that 50% of heart attack victims have normal cholesterol levels? Obviously there must be much more involved, which you will see shortly.

My take home point is that therapy needs to be individualized. As an integrative cardiologist do I prescribe statins? Certainly I do, but I reserve such treatment for high risk patients where research has unequivocally demonstrated the benefits.

Nearly 80% of cholesterol is produced in the liver. A much smaller amount is absorbed through the gut. Genetics clearly play a role here. Regardless of what you ingest, your liver will produce more or less depending on what the body needs.


Cholesterol doesn’t circulate by itself. It is accompanied by proteins. Hdl ,which I call “healthy” lipoprotein removes cholesterol from the circulation and sends it back to the liver for disposal. This process is known as reverse transport. Ldl or “lousy” lipoprotein is cholesterol transported throughout the body.  One place it travels is the brain where it is greatly needed. 

So is Ldl cholesterol truly lousy? My answer is no, unless it has been chemically altered or oxidized and/ or the Ldl particle number is extremely high.  Oxidized Ldl cholesterol is the culprit. It can attack the walls of our arteries and start the process of plaque formation.  Inflammation ensues.

So who really needs to be treated? Certainly those with known coronary disease are at high risk.   Research dating back 20 plus years has proven that treating these patients aggressively saves lives. This is referred to as secondary prevention. It is here that I am in total agreement with my cardiology colleagues. This includes those who have experienced a heart attack or stroke, have documented coronary disease and those who have undergone procedures such a balloon angioplasty /stent or bypass graft surgery. We extend this high risk group to diabetics as 70% of diabetics will experience a heart attack or stroke in their lifetime. 

What about primary prevention? Should we be treating those with elevated cholesterol who have no documented heart disease? Therein lays the gray zone. Again, my answer is individualize the therapy.


Practicing functional medicine, my aim is to uncover the cause of the malady whenever possible. For me, it’s not merely about lowering the numbers, but deciding who really needs treatment. It’s about patient stratification.  I employ specialized lab testing to help me in this regard. 

For example, let’s say that a standard lipid panel comes back abnormal. Many physicians, guided by Big Pharma might start treatment with a statin. This includes many cardiologists. Choosing a different strategy, I proceed with the testing mentioned above. I ‘m interested in the size of the actual particles. Not all Hdl is healthy and not all LDL is lousy. All you need to remember is that bigger is always better!  Large Hdl particles confer cardiac protection while large LDL particles pose less of a threat than small dense particles. Small dense particles are 40% more likely to get oxidized when compared to larger, more buoyant Ldl particles. 

Not only does the particle size of lipids matter with regard to risk, but the treatment differs. Statins do a great job and are unparalleled    in lowering the Ldl particle  number. However, they do nothing to alter the size of the particles. That’s when the role of diet comes into play as well as the use of niacin.


Then there is this poorly appreciated cardiac risk factor known as Lp(a). This abnormality, a fragment of Ldl cholesterol is genetically determined. You may have heard little about it, but it is extremely atherogenic. This means it’s a plaque former. It can be  associated with significant coronary disease. One reason why you hear so little about it is because statins don’t touch it. In fact there are currently no pharmaceutical agents available that lower it. Think about that for a second. There is nothing Big Pharma has to market ! However, niacin may in many cases help out in this regard.

So particle size and number and determining Lp(a) are important as far as I am concerned. This is  especially so when choosing  the appropriate treatment. There are other markers for which I regularly test: inflammatory markers, metabolic markers and genetic markers. 

Inflammation is the bane of our existence when it comes to aging. Sure heart disease still tops the list, but inflammation also leads to cancer, autoimmune disorders and Alzheimer’s disease. A part of me is actually more interested in whether you have inflammation that what are your actual numbers.

So remember it may start with your numbers, but there is so much more. Are we treating secondary prevention where statins have a well-established role? This strata of the population needs to be treated aggressively as to avoid subsequent cardiac events. 

Are we talking about primary prevention? This may seem to be less of an urgent concern, but nonetheless may be quite important. Risk stratification is mandatory in these cases. .What is the size of the Hdl and Ldl particles? Is Lp(a) elevated? Is there a metabolic issue such as prediabetes, diabetes or metabolic syndrome? Is inflammation present? Not everyone needs to be placed on a statin.

All this information is readily available with specialized laboratory testing. If you are a member of Kaiser or an HMO, good luck! I hear on the radio all this talk about thrive, yet I’ve yet to see them cover these preventative services. However, there are labs out there that can uncover this information at an affordable price.

Whose body is it? It’s your body. So please take my lead in becoming your own medical advocate. When it comes to cholesterol, it's not just about knowing your numbers. It's about knowing your risk.  Stay in the driver’s seat when it comes to your health.

Yours in health,

Howard Elkin, MD.

Howard Elkin MD