But we figured that it actually made a pretty great standalone episode. So today, we're back with a cholesterol 101, if you will.
Listener M wrote in with the question: I'm very interested in the correlation between high cholesterol and what we eat. It seems to me that the high cholesterol always comes with the diet stuff. Less red meat, less fat in the diet, etc. Is this really true? It feels very shameful to have high cholesterol that you have somehow behaved badly. A sign (almost like being fat) that there is something wrong with you. (Or your diet.) Can you clear this up for me?'
We went deep and discussed:
🫘 What a diagnosis of 'high cholesterol' really means ♥️ What function cholesterol plays in the body (and why we need it!) 🫘 The difference between HDL and LDL cholesterol (and why you can't ascribe moral value to molecules that float around in your blood) ♥️ Whether weight-loss actually helps lower cholesterol 🫘 Some social and structural reasons we might experience higher LDL cholesterol ♥️ How we can support our heart health sans diets 🫘 Gentle nutrition pointers and some great recipe ideas for caring for ourselves if we have 'wonky' cholesterol 🪐 Why tuna is the Pluto of the nutrition world 🐡 My fish-phobia origin story
Cholesterol 101
This following advice is provided for educational purposes only. Please talk to your doctor or a registered nutrition professional before making changes. If you have a tricky relationship with food and/or are managing multiple health concerns and working with a non-diet health professional is available to you, I'd really recommend seeking out their support. I'm giving you lots of gentle nutrition options, because that's kind of my whole deal. But just know that nutrition is only 1 part of this particular puzzle, and it doesn't have to be your focus if that doesn't feel supportive.
I could easily write a whole series on Cholesterol, buy I'm going to attempt to keep this tight enough for the attention economy. If you want more detail, then please check out this guide we put together at LCIE, or check out the full bonus podcast below!
Cholesterol is a type of fat essential in our bodies. It forms part of the structure of our cell membranes, it's important for hormone production, and it’s involved in vitamin D synthesis in our skin. The liver produces cholesterol but a lot of cells can make it too.
Because cholesterol is a fat, it can't float around freely in our blood; a sort of oil and water/vinegar situation. You need an emulsifier. This is the job of a lipoprotein - essentially a protein molecule that is attached to a lipid (fat).
This is a bit of an oversimplification, but there are essentially two main types:
High density lipoproteins (HDL cholesterol) takes cholesterol you don’t need back to the liver to be broken down and passed out of the body. It’s often known as ‘good’ cholesterol as it removes cholesterol from the blood (but as we discuss in the pod, you can't ascribe moral value to molecules so think of HDL cholesterol as the 'helpful' stuff).
Non-high-density lipoproteins (Non-HDL cholesterol, including low-density lipoproteins, or LDL) take cholesterol from the liver to the cells around the body. It’s often known as ‘bad’ cholesterol because when there is too much, it can build up in your arteries. This can cause them to become narrowed or blocked and increase your risk of having a heart attack or stroke.
When a doctor hands out a diagnosis of 'high-cholesterol', usually what they mean is that the ratio of HDL:LDL is, a bit wonky. This means that there’s more LDL cholesterol depositing fats in the body than there is HDL to clear away the excess. This is known as dyslipidemia.
This isn't your fault, and it's not a moral obligation or personal responsibility to be 'healthy'. It's not because you're fat. It's not because you have a 'bad' diet. It's not because you failed at being a 'good' person somehow. Sure, there are things we can do to help redress the balance of HDL and LDL, but, it's important to know that 'high cholesterol' can happen to people of all ages, genders, sizes (including very thin/'underweight' folks). Raised LDL cholesterol can be related to other health conditions like PCOS, diabetes, liver and kidney disease, and some medications. It can be more common in people of Celtic and South Asian ancestry and there are strong genetic links, meaning it often runs in families.
Stress plays a big role in dyslipidemia. Cortisol, which is involved in stress response, actually increases the level of LDL in our bodies. This is helpful when we have an actual threat we need to get away from because it helps produce glucose and free fatty acids that our body can use for energy. But if you’re experiencing long-term stress (like racism, ablism, late-stage capitalism, unliveable housing etc...) then this can lead to persistently raised LDL levels. And obviously weight stigma and anti-fat bias are also forms of chronic stress for fat folks. Although we are told to 'manage' our stress, this ignores the amount of privilege required to live without a significant amount of stress.
As I say in the podcast - out of whack cholesterol is not a medical emergency. You have some time to feel your way into what would be supportive and accessible for your particular circumstances. Maybe adding more movement in is just not an option for you right now, so medication or supplements might be the way to go. Or perhaps you've been waiting for something to nudge you to go for a swim and this has been the push you needed. There is no right or wrong way to tackle this, but I am here to remind you that you don't need to shrink your body to care for your health. In fact, listen to the pod for some surprising* research around the relationship between cholesterol and diets. * Or completely unsurprising, depending on how you slice it. That said, here are some other things we can do to support wellbeing.
Medications: Statins are a super helpful class of drugs that are safe and effective (although not appropriate for everyone, so speak with your doc as other medications are available) that help reduce the amount of non-HDL cholesterol made in the liver. It can be a great option if 'lifestyle' changes are inaccessible to you for any reason. Absolutely no shame in the statin game.
In terms of gentle nutrition, I always think about what it might be helpful to add in, rather than pushing a fatphobic weight loss agenda, or pushing a restrictive eating pattern.
Supplements. This is typically where I'd start with a client, particularly if gentle nutrition and 'lifestyle' changes felt inaccesible or too much of a head fuck.
First up is psyllium husk. This is likely to have the biggest impact for the smallest effort. Look, there's no way around it. It's kind of gross. If you're not familiar with psyllium husk, it comes as a powder that you dissolve in a glass of water or in pill form (but you need a lot of pills to get the recommended dose). It works by absorbing cholesterol rich bile in the GI tract so it doesn't get reabsorbed into the body. In N. America you can find it under the brand name Metamucil (but heads up that you will have to wade through some fatphobic/appetite suppressant stuff. It will definitely make you shit, but that's about it). You'd need 10g/day to reach a clinically meaningful reduction in LDL cholesterol. You need to make sure you drink plenty of water with psyllium so you don't get constipated. And it interacts with several drugs and tests your doctor might administer. Talk to them about how to appropriately space apart any medications (usually 2 hours before/after psyllium). If you have a sensitive digestion system, then supplementing with other sources of fibre, like ground flax seed may be a better starting point. Regardless, you don't want to go too hard too fast with fibre unless you want to shit your pants. Best to introduce gradually over days and weeks. Again, talk to an HCP if you're not sure.
Foods fortified with plant stanols and plant sterols can help reduce LDL cholesterol by ~10% in around 3 weeks, when eating 2-3g/day. These act by blocking reabsorption of non- HDL cholesterol from bile in the digestive tract, reducing circulating levels in the blood. You can try a fortified spread like Flora or Benecol (you'd need around 3 servings a day), or you can try a fortified yoghurt or yoghurt drink that contains at least 2g per serving. You can find out more about this on the BDA website here.
More gentle nutrition. Ok so, I don't know your preferences, budget, cooking skills, equipment, confidence in the kitchen, time to cook, access to food, or really anything about your circumstances so my suggestions may not work for you. Think of this as just a starting point. You don't have to do all of these things (or any, remember not a medical emergency). It's a choose your own adventure situation and I'm happy to answer Qs in the comments.
Vitamin F: Contrary to what you might have heard, you don't have to follow a strict, low-fat diet to support heart health. Adding in foods high in mono- and poly-unsaturated fats goes a long way.
Salmon or haddock fishcakes or even frozen salmon fillets or salmon fish fingers; canned sardines or mackerel on toast/in a salad. Even swapping cans of tuna for cans of salmon/mackerel every now and then can make a difference! Listen to the episode for Lucy's fish recipe reco.
Cooking with rapeseed (canola) or olive oil. Or avocado oil if you're fancy.
Nuts, seeds, and nut and seed butters are all great sources of unsaturated fats. Eat them however you enjoy them, or find something else you prefer if you don't dig them. It could be toasted pumpkin seeds to add crunch. Seeded granary bread. Ground flax seed thrown in a smoothie/porridge/whatever. Nut/seed butter chocolate cups (or straight from the jar, no judgement).
Now I know how this sounds. But tofu, and soy products broadly, are great for helping redress that balance between LDL and HDL cholesterol. Again, a pick your own adventure situation. Find what works for you: tempeh crumbles, firm tofu in your curry, edamame beans thrown into a stir-fry or in a rice bowl, you could switch up the mince in your chilli or burrito for soy-based mince (you can find dried stuff that you rehydrate that's cheap and lasts for ages). Or you could give soy-based milk, yoghurt or other products a try. Now whereas Lucy knows her fish, having been vegan for 20 years I think makes me qualified to talk about tofu. Don't fuck with the silken stuff unless you're in Japan (or you want to make a silky smooth sauce. Invest in a tofu press if you're serious about tofu. Otherwise find the extra-firm stuff. Cut it into cubes or slices and bake it in a hot oven with S&P, (and some oil but it doesn't need loads) to get a good crust, then toss it in whatever sauce you like. I also love this ramen situation by Eric Kim (NYT gift link), and this tofu scramble is buttery and spicy and SO GOOD. On the tempeh front, highly recommend these chilli crisp tempeh crumbles (and the whole coconut rice business too). You can also buy more convenient pre-marinated tempeh ranging from 'facon' flavour all the way to sweet chilli and 'curry' flavour. Your milage may vary with those, so it's worth experimenting to find something you like. But honestly, you can't go wrong with frying in olive oil and hitting it with flaky salt and nutritional yeast. Any other tofu/tempeh freaks out there - let me know your favourite recipes in the comments!
Fibre: If none of the above sounds appealing, then another route you can go down is trying to increase your fibre intake. Now, I'm not talking about 30 plant-per-week here. I'm talking about switching up white bread for wholemeal if it's not that big a deal to you.
The song is true; beans are good for your heart. So are lentils/pulses/legumes. Chickpeas; kidney beans; lentils; black eyes peas; butterbeans; black beans;
And whole grains like oats, barley, quinoa, brown rice, bread, pasta (but no shade to white) are all 10/10.
Again, do what works for you: overnight oats, porridge and granola are great, but if they're not for you, granola bars and oaty biscuits (like Nairns) and oat cakes are excellent choices too. You can add kidney or black beans to your chilli or burrito. Or you could do baked beans on toast. Shop bought hummus and falafel are super convenient and easy to stuff into a pita for a quick lunch (just add whatever accessories you need to make it a meal). A baked potato with the skin is also great.
Breakfast cereals like Weetabix, Shredded Wheat, and Cheerios are all great options too.
Chunky soups that are lentil/bean based are awesome (and you can buy supermarket versions if that's easier for you). Just make sure you add some bread and other bits to make it a full meal.
Chunky nut butters (peanut/almond etc...) on wholemeal toast/bagel makes a fab snack. Or again, avocado if you fancy.
Alright team - for more, check out the episode with Lucy below. We'll share a little more detail about cholesterol, the factors that can affect it, why Tuna is the Pluto of the nutrition world, my fish-phobia origin story, and some more recipes we like.
