Women: Let’s Talk Cholesterol

Note from Dave: This long-awaited installment from Siobhan is a must-read for every female interested in cholesterol and risk. Enjoy!

The First Hint

As the #LDLBounty continues, and the question of whether high LDL in isolation raises the risk of cardiovascular mortality (or all-cause mortality) in and of itself remains unanswered, there may be a group which may give one even more pause when contemplating the answer. My first hint that things weren’t exactly equal in regards to cholesterol between men and women was way back in 2015. Far before I had even thought about picking up a textbook on lipidology, I noticed there seemed to be something a little odd going on in regards to women and high cholesterol levels. For one, I had heard talk of some research that women with low cholesterol were more at risk for symptoms of depression1, 2, and while I found this interesting it was merely an association. So what if you’re less likely to become depressed if you have higher cholesterol as a woman? You’ll still be more likely to die of things like heart disease, and die more over all, anyway.

Right?

More Cholesterol, Less Death

In fact, there appears to be a bit of a difference when it comes to women and men in regards to mortality risk when it

From: doi:10.1111/j.1365-2753.2011.01767.x

comes to cholesterol. Because, while in men it appears as though there’s a U shaped risk when it comes to

cholesterol levels – meaning that rates of death are higher with lower and higher total cholesterol – with women it appears to be quite a bit more simple. As stated in the paper3, in women it appears as though when cholesterol levels are higher, death from all causes is lower.

That study didn’t appear to be a random fluke, either. As time went on I found more4, and more5 and more6 studies all showing that, specifically in women, either there was no difference in death from all causes with varying cholesterol levels, or those in the lowest cholesterol group had the highest rates of mortality. But, admittedly, this is looking at total cholesterol, so I thought that at the very least higher LDL (often considered the true bad guy in regards to cholesterol) would correlate to higher mortality rates.

More of the Same

Even after looking for studies which looked at LDL levels in regards to the rate of mortality and cardiovascular disease, the result ended up being the same with studies I encountered generally coming to similar conclusions. Some said that LDL levels in women were “not significantly related” to all-cause mortality7, while other said that LDL was not associated with Peripheral Artery Disease in women8, and yet more indicating variations of the same result.9, 10

But, clearly women aren’t bulletproof when it comes to cardiovascular disease, as they get it at about the same rates as men do, and it’s not like we’re especially good at avoiding death in general (as much as we might like to think of ourselves as invincible), either. So, it doesn’t appear as though this is a case of women being immune to cardiovascular disease, or being particularly resistant to death, so much as total cholesterol and LDL seemingly being poor predictive markers for women.

Now What?

If neither LDL nor total cholesterol is especially predictive in women, then what can we look for to determine our risk? Some studies indicate other, potentially more relevant markers for women, and luckily no additional tests need be ordered, as the information can be found on a standard lipid panel.

For example several studies found that the ratio of triglycerides to HDL were predictive of carotid plaque11, insulin resistance12, 13 (which is related to increased cardiovascular disease risk), cardiovascular mortality14 and all-cause mortality in women.15 Atherogenic Index of Plasma (AIP) also has some promise to better predict all-cause mortality among women.16 Although AIP is unlikely to show up on your lab report, you can easily calculate it via our report tool so long as you have your triglyceride and HDL levels.

While these markers do appear to predict cardiovascular and all-cause mortality risk better than Total Cholesterol or LDL this doesn’t mean that these markers are perfect. For one, both of these measures can be impacted by how long you fasted before the test, as well as issues which may raise triglycerides in isolation. Use of medication which influences HDL and triglycerides may also potentially interfere with their value as health markers, as well, so looking at multiple risk markers together may help avoid some of the pitfalls of relying on one marker alone.

Final Note From Siobhan

 

As always, the evaluation of personal health is a topic that, first and foremost, should be had with your doctor. Likewise, we always recommend researching all reputable sides of this debate as we do ourselves.

 

 

 

Sources

Horsten, Myriam, et al. “Depressive Symptoms, Social Support, and Lipid Profile in Healthy Middle-Aged Women:” Psychosomatic Medicine, vol. 59, no. 5, 1997, pp. 521–28. Crossref, doi:10.1097/00006842-199709000-00009.

Persons, Jane E., et al. “Longitudinal Study of Low Serum LDL Cholesterol and Depressive Symptom Onset in
Postmenopause.” The Journal of Clinical Psychiatry, vol. 77, no. 2, Feb. 2016, pp. 212–20. PubMed, doi:10.4088/JCP.14m09505.
Petursson, Halfdan, et al. “Is the Use of Cholesterol in Mortality Risk Algorithms in Clinical Guidelines Valid? Ten Years Prospective Data from the Norwegian HUNT 2 Study.” Journal of Evaluation in Clinical Practice, vol. 18, no. 1, Feb. 2012, pp. 159–68. PubMed, doi:10.1111/j.1365-2753.2011.01767.x.
Forette, B., et al. “Cholesterol as Risk Factor for Mortality in Elderly Women.” Lancet (London, England), vol. 1, no. 8643, Apr. 1989, pp. 868–70.
Higgins, M., and J. B. Keller. “Cholesterol, Coronary Heart Disease, and Total Mortality in Middle-Aged and Elderly Men and Women in Tecumseh.” Annals of Epidemiology, vol. 2, no. 1–2, Mar. 1992, pp. 69–76.
Choi, Ji-Sook, et al. “Serum Total Cholesterol and Mortality in Middle-Aged Korean Women.” Atherosclerosis, vol. 192, no. 2, June 2007, pp. 445–47. PubMed, doi:10.1016/j.atherosclerosis.2007.03.006.
Nilsson, Göran, et al. “Ten-Year Survival in 75-Year-Old Men and Women: Predictive Ability of Total Cholesterol, HDL-C, and LDL-C.” Current Gerontology and Geriatrics Research, 2009, p. 158425. PubMed, doi:10.1155/2009/158425.
Aday, Aaron W., et al. “Lipoprotein Particle Profiles, Standard Lipids, and Peripheral Artery Disease Incidence – Prospective Data from the Women’s Health Study.” Circulation, July 2018, p. CIRCULATIONAHA.118.035432. DataCite, doi:10.1161/circulationaha.118.035432.
Hamazaki, Tomohito, et al. “Towards a Paradigm Shift in Cholesterol Treatment. A Re-Examination of the Cholesterol Issue in Japan.” Annals of Nutrition & Metabolism, vol. 66 Suppl 4, 2015, pp. 1–116. PubMed, doi:10.1159/000381654.
10 Bass, Katherine Miller. “Plasma Lipoprotein Levels as Predictors of Cardiovascular Death in Women.” Archives of Internal Medicine, vol. 153, no. 19, Oct. 1993, p. 2209. Crossref, doi:10.1001/archinte.1993.00410190045006.
11 Masson, Walter, et al. “Association between Triglyceride/HDL Cholesterol Ratio and Carotid Atherosclerosis in Postmenopausal Middle-Aged Women.” Endocrinologia Y Nutricion: Organo De La Sociedad Espanola De Endocrinologia Y Nutricion, vol. 63, no. 7, Sept. 2016, pp. 327–32. PubMed, doi:10.1016/j.endonu.2016.04.004.
12 Murguía-Romero, Miguel, et al. “Plasma Triglyceride/HDL-Cholesterol Ratio, Insulin Resistance, and Cardiometabolic Risk in Young Adults.” Journal of Lipid Research, vol. 54, no. 10, Oct. 2013, pp. 2795–99. PubMed, doi:10.1194/jlr.M040584.
13 González-Chávez, Antonio, et al. “Elevated Triglycerides/HDL-Cholesterol Ratio Associated with Insulin Resistance.” Cirugia Y Cirujanos, vol. 79, no. 2, Apr. 2011, pp. 126–31.
14 Mazza, A., et al. “Triglycerides + High-Density-Lipoprotein-Cholesterol Dyslipidaemia, a Coronary Risk Factor in Elderly Women: The CArdiovascular STudy in the ELderly.” Internal Medicine Journal, vol. 35, no. 10, Oct. 2005, pp. 604–10. PubMed, doi:10.1111/j.1445-5994.2005.00940.x.
15 Bittner, Vera, et al. “The Triglyceride/High-Density Lipoprotein Cholesterol Ratio Predicts All-Cause Mortality in Women with Suspected Myocardial Ischemia: A Report from the Women’s Ischemia Syndrome Evaluation (WISE).” American Heart Journal, vol. 157, no. 3, Mar. 2009, pp. 548–55. PubMed, doi:10.1016/j.ahj.2008.11.014.
16 Bendzala, Matej, et al. “Atherogenic Index of Plasma Is Positively Associated with the Risk of All-Cause Death in Elderly Women : A 10-Year Follow-Up.” Wiener Klinische Wochenschrift, vol. 129, no. 21–22, Nov. 2017, pp. 793–98. PubMed, doi:10.1007/s00508-017-1264-1.
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hayley
hayley
2 years ago

Thanks for doing this important work! I have high LDL cholesterol in isolation but had a CT Scan that showed I have absolutely no evidence of coronary artery disease! I am 53 and have been doing LCHF since November 2016. I believe I am going to live a good long time!!

فروشگاه اينترنتي

There should be results for the upper and lower levels of Cholesterol and a careful and accurate examination to consider the possible risk for fat and cholesterol levels.
https://www.baneh.com
thanks

BobM
BobM
2 years ago

In your review of the literature, did you find that HDL became “good” because people were trying to determine why women’s heart disease rates were lower than men’s and came up with this idea? (This has always been my understanding, but could be — and likely am — wrong.)

Also, is there one reference study we could use (say, a meta-analysis or review) to illustrate this concept? I always say that higher TC (or even LDL) appears to be protective for women, but then I don’t have anything to back that up, other than all the people whose views I trust and who have researched this say this is the case.

And this points out yet another reason our older-male-dominated medicine fails: researchers (men) think that what applies to older men should apply to everyone else, women, children, etc., and that may or may not (in many cases, is not) true.

Adam G
Adam G
2 years ago

Sorry to but in with a different topic but did you post your final results from the beef vs pork tests anywhere or Did the video CCW4 cover it? Thank you sorry again for interrupting

Adam G
Adam G
2 years ago

Awesome looking forward to it

Frank Tufano
2 years ago

Hey Dave do you have any idea of a solely fish diet over 1-2 weeks would drastically impact cholesterol? My LDL has tested anywhere between 350 (after 2 weeks of fasting) and 220 (fasted 12 hours), I’m tempted to test it out for a week or two.

The idea was:
Normal Diet for 1 week, fast 12 hours, get blood results
Only fish/light calories/fasting for 2 weeks, fast 12 hours, get blood results
fast 1 more week, get blood results

مدل های حصار گوزنی
Reply to  Frank Tufano

مطلب بسیار باحالی بود و ممنوم از شما

Susan P.
Susan P.
2 years ago

Thank you for the AIP report tool. I put in my numbers and got an answer of
AIP: -0.252 >>> Lowest Risk Third Is that a truly a negative number? That seems too good to be true!

Colaroygal
Colaroygal
2 years ago

Siobhan, I am assuming these are all good? Can you confirm. I am not really familiar with AIP especially. Thank you for all you do here and on the KKAB page.

Kelle Clark
Kelle Clark
2 years ago

I’m preparing for my first blood testing after 6 months Keto and Carnivore for the last 4 months. I will be going to Quest Diagnostics and will be self-paying, so I want to get the most bang for my bucks 🙂 A semi-retired Naturopath has offered to call in my prescription, but is unsure what to request considering my WOE and cholesterol concerns. I have had kidney stones n the past (last bout 2 years ago) so I also want these levels checked. I was overwhelmed at the number of test available on the Quest website and wonder if you can help me out? I will be posting my results as soon as I receive them. Thanks for all your great work!

Kelle

June
June
2 years ago

What are good studies to give your doctor when they want you to start on statins?

Ricks
Ricks
2 years ago

Most of the studies and discussion I see about cholesterol and disease is all about impact on coronary disease. What about stroke risk? and Small Vessel Disease (SVD) in the brain? can we translate effects of diet and cholesterol on the heart and it’s vascular system to the brain and it’s blood vessels?

Michele
Michele
1 year ago

Siobhan, thanks for the great article! Just got my labs back. Been LCHF for a year or greater, not sure. Labs seemed good but WBC and RBC were low-ish, 3.9 and 4.11 respectively. Not sure if that’s a dehydration thing or not. What I find interesting was my A1c (5.1) and Trig (56) were good, my glucose was 118. Wondering if you had thoughts on this.

Thanks! Keep on Keeping on!! 🙂

Michele

-==== CholesterolCode.com/Report v0.9.3 ====–
…012 months on LCHF (20g to 120g carbs) ::: 18 hours water fasted…
Total Cholesterol: 236 mg/dL 6.1 mmol/L
LDL Cholesterol: 118 mg/dL 3.05 mmol/L
HDL Cholesterol: 100 mg/dL 2.59 mmol/L
Triglycerides: 56 mg/dL 0.63 mmol/L

–CHOLESTEROL REMNANTS–
Remnant Cholesterol: 18 mg/dL 0.47 mmol/L >>> Medium-Low Risk Quintile
Remnant Chol to HDL: 0.18 >>> Lowest Risk Quintile
Go to https://tinyurl.com/y84u92wm for more on Cholesterol Remnants

–ATHEROGENIC INDEX OF PLASMA (AIP)–
AIP: -0.614 >>> Lowest Risk Third
Go to https://tinyurl.com/ycccmmnx for more on Atherogenic Index of Plasma

–CONVENTIONAL MARKERS AND RATIOS–
Friedewald LDL-C: 125 | Iranian LDL-C: 99
Total/HDL Ratio: 2.36
TG/HDL Ratio in mg/dL: 0.56 | in mmol/L: 0.24

Michele
Michele
1 year ago

Thanks for the quick response. I did go for a 3 mile run the morning of the blood draw. I do try to workout regularly but as of lately, there hasn’t been a lot of resistance work. I have not had my fasting insulin done. Unfortunately not on this work up – need to find somewhere to get it ordered. Would dehydration after a workout play into it?

borroni francesca
borroni francesca
1 year ago

on diet:

12
total hours WATER fasted before the test.
(In other words, total time between your
last meal or coffee/beverage and the blood draw for this test.)

Units of measurement:

327
Total Cholesterol (TC)

196
LDL Cholesterol (LDL-C)

110
HDL Cholesterol (HDL-C)

43
Triglycerides (TG)

(Copy and paste everything below for reuse)

–==== CholesterolCode.com/Report v0.9.3 ====–
…5 months on Keto (less than 20g carbs) ::: 12 hours water fasted…
Total Cholesterol: 327 mg/dL 8.46 mmol/L
LDL Cholesterol: 196 mg/dL 5.07 mmol/L
HDL Cholesterol: 110 mg/dL 2.84 mmol/L
Triglycerides: 43 mg/dL 0.49 mmol/L

–CHOLESTEROL REMNANTS–
Remnant Cholesterol: 21 mg/dL 0.54 mmol/L >>> Medium-Low Risk Quintile
Remnant Chol to HDL: 0.19 >>> Lowest Risk Quintile
Go to https://tinyurl.com/y84u92wm for more on Cholesterol Remnants

–ATHEROGENIC INDEX OF PLASMA (AIP)–
AIP: -0.763 >>> Lowest Risk Third
Go to https://tinyurl.com/ycccmmnx for more on Atherogenic Index of Plasma

–CONVENTIONAL MARKERS AND RATIOS–
Friedewald LDL-C: 208 | Iranian LDL-C: 159
Total/HDL Ratio: 2.97
TG/HDL Ratio in mg/dL: 0.39 | in mmol/L: 0.17

borroni francesca
borroni francesca
1 year ago

in your protocol no vegetables al all? Just meat and cheese for three days?
-==== CholesterolCode.com/Report v0.9.3 ====–
…5 months on Keto (less than 20g carbs) ::: 12 hours water fasted…
Total Cholesterol: 327 mg/dL 8.46 mmol/L
LDL Cholesterol: 196 mg/dL 5.07 mmol/L
HDL Cholesterol: 110 mg/dL 2.84 mmol/L
Triglycerides: 40 mg/dL 0.45 mmol/L

–CHOLESTEROL REMNANTS–
Remnant Cholesterol: 21 mg/dL 0.54 mmol/L >>> Medium-Low Risk Quintile
Remnant Chol to HDL: 0.19 >>> Lowest Risk Quintile
Go to https://tinyurl.com/y84u92wm for more on Cholesterol Remnants

–ATHEROGENIC INDEX OF PLASMA (AIP)–
AIP: -0.8 >>> Lowest Risk Third
Go to https://tinyurl.com/ycccmmnx for more on Atherogenic Index of Plasma

–CONVENTIONAL MARKERS AND RATIOS–
Friedewald LDL-C: 209 | Iranian LDL-C: 158
Total/HDL Ratio: 2.97
TG/HDL Ratio in mg/dL: 0.36 | in mmol/L: 0.16

Are there any risk for me?

Sarah
7 months ago

–===== CholesterolCode.com/Report v0.9.5.15 =====–
• Female • 48 • Coffee: 0 cups/day •
• 5 on months on LCHF (20g to 120g carbs) •
• 17h water fasted • Cholesterol Rx: false •

Total Cholesterol: 303 mg/dL 7.84 mmol/L
LDL Cholesterol: 183 mg/dL 4.73mmol/L
HDL Cholesterol: 113 mg/dL 2.92mmol/L
TG Cholesterol: 35 mg/dL 0.4mmol/L

———RISK REPORT———
Atherogenic Index of Plasma: -0.863 mg/dL >>> Lowest Risk Third
—-> Go to https://tinyurl.com/ycccmmnx for more on AIP

Framingham Offspring: 0.7 Odds Ratio >>> Low Risk
—-> Go to https://tinyurl.com/y5fc5adl for more on this Framingham study

Jeppesen: >>> Lowest Risk Third
—-> Go to https://tinyurl.com/y63xp7lj for more on the Jeppesen study

Cholesterol Remnants: 7 mg/dL >>> 0.08 mmol/L >>> Low Risk
—-> Go to https://tinyurl.com/y84u92wm for more on Cholesterol Remnants

——CONVENTIONAL MARKERS AND RATIOS——
Friedewald LDL-C: 183 | Iranian LDL-C: 132
TC/HDL Ratio in mg/dL: 2.68
TG/HDL Ratio in mg/dL: 0.31 | TG/HDL Ratio i

This report is from November..and after I’ve been grain free for about 5 months ( I have celiac disease but I seem to react to all grains, esp hidden corn). I was mainly living on lots of eggs at the time as that was the only thing I could tolerate. Since then I found I can eat lamb from New Zealand. Other meats seem to cause issues. I eat very clean and it’s not unusual for me to walk for 3 or 4 hours at a time. I’ll do that several times a week. I also carry all of my groceries home from a few stores, carrying then miles. I can carry 20 pounds for about 2 miles without any problems..I prefer to do all.of my walking on an empty stomach, so only drinking water.

I’m feeling better and I’ve noticed other improvements too. Like some wrinkles I had on my forehead seem to be almost gone. And any injury seems to heal really fast?!

The longest I’ve ever fasted was about 25 hours. Because I’m worried about getting all of my nutrition. I need my body to heal from 20 years of undiagnosed celiac which has taken a big toll.

The advice from my doctor was to eat “healthy whole grains” everyday when I have celiac disease! Which is crazy. I even react to airborne particles from places that are cooking grain, like if I walk past a bakery or a fast food. I started OMAD and keto hoping some of these reactions might go away..the airborne ones I mean. I started keto in January.

The hemoglobin A1C says
Ref range & units: 4.0 – 5.6 percent. 5.0

I guess my number is 5.0???

Oh the other advice the paper gave to “lower cholesterol” is to “start walking” and that I should stop eating eggs, cheese and red meat. Well due to reactions to most normal food I won’t be able to eat anything!! I’d be stuck living on lettuce! How can I walk to where I need to go if I’m living on lettuce? I also can’t get the nutrition from that. You can’t get B vitamin or iron from lettuce! Oh I walk 3.5 or 4 miles per hour. I also do body weight training. And I lift small weights.

I don’t seem to catch cold or flu even if people cough on me.

The Dr did want to prescribe some junk but I’m not taking anything. I can’t even take over the counter stuff, like a cough drop, as I react to it. So I don’t trust anything.

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