Navigating Cholesterol: My Personal Journey with Statins and Heart Health

Like so many people, heart health is a major concern for me. I have heart disease on both sides of my family and several family members have had heart attacks.

For the most part I think my lifestyle is pretty dialed in, I sleep well, exercise regularly (although I am sure at some points my exercise volume could border on being detrimental), don’t smoke, eat a whole foods diet, try to manage my stress, etc.

Unfortunately despite having a lifestyle that is far healthier than the average Westerner my cholesterol numbers look like a “train wreck” (at least when viewed in the traditional perspective). For better or worse, we have been conditioned to think that if your cholesterol is high you are going to eventually get heart disease. While I realize this isn’t as black and white as we have been led to believe, it still causes me some concern whenever I get my blood work results a few times a year.

Some Background

To give you an idea of what my cholesterol numbers look like, some data I have collected since 2016.

My total cholesterol is always over 200 mg/dl and many times pushes close to 300 mg/dl (occasionally over). Generally most doctors want this number to be 200 mg/dl or lower.

My LDL cholesterol, traditionally considered the “bad cholesterol”, has always been above 130 mg/dl and sometimes 200 mg/dl or more. Generally most doctors want this number to be 100 mg/dl or less.

There are two other lipid markers that are also very important when it comes to heart health, Lipoprotein A (LPA) and Apolipoprotein B (APOB).

Lipoprotein A carries fat and cholesterol throughout the body and it is 70-90% genetically determined meaning you don’t have very much control over it (Berglund, 2016). For this reason it only makes sense to test LPA once to see if it is high or low. When I tested mine it came back at 17 mg/dl and generally doctors want it below 50 mg/dl. Thankfully that marker looks ok.

My APOB is a different story. APOB is important because it is part of ALL heart disease causing lipids (not just LDL). The traditional thought is that LDL is the bad cholesterol particle, but there are also particles called IDL, VLDL, chylomicrons and chylomicron remnants which can also cause heart disease. APOB is part of all of these. Therefore the thought is by measuring APOB you are getting a more complete picture of all the heart disease causing particles in your body.

My APOB number has always been elevated, although I don’t have as many data points for it as I do my other cholesterol numbers. Ideally doctors would like to see APOB less than 90 mg/dl and mine is generally in the 130 mg/dl range.

My triglycerides are always 90 mg/d or less, generally in the 70s or so. In general it is considered optimal to have triglycerides 100 mg/dl or less.

My HDL, often considered the good cholesterol, also has always looked good with it generally being in the 60-70 mg/dl range . Generally you want your HDL to be 40 mg/dl or greater.

My insulin, glucose, c-peptide, A1C, and HS-CRP have always been very good as well. These are all very important because when you have inflammation (as represented in HS-CRP) and/or you are insulin resistant (as measured with insulin, glucose, c-peptide, and A1C) it is more likely that high cholesterol can lead to cardiovascular disease.

Many people in the “ancestral health space” looking at my blood work above would basically say there is nothing to worry about here. I am metabolically healthy with no signs of inflammation and my lifestyle is on point so the LDL and APOB should be harmless. Then there will be others that still think that I should try and manage my lipids better and that with those LDL and APOB numbers I am asking for trouble.

Frankly I am not smart enough to know who to believe.

Sometimes I can put my lipid numbers aside and look at everything else and think I am fine.

Then there are times I look at my lipids and then look at my family history and get worried that I could be doing more to better protect myself from potential heart disease.

Assessing My Current Risk

Up until recently I haven’t been terribly worried about my lipids and heart health but lately I have been thinking more and more about longevity and being around as long as possible for my family and have a bit of a change of heart (pun intended). I want to make sure I am not taking any unnecessary risks.

The first thing I did was decide to get a better picture of my current cardiovascular disease burden.

So four to five years ago when I was 35 I got a coronary artery calcium scan (CAC scan). This scan can detect and measure the amount of hard plaque in your arteries. ThanKfully when the results came back I was given a score of 0, meaning I had no signs of plaque.

I felt really good about that, but I also learned that I am less likely to have any hard plaque at 35 (my age at the time) because plaque takes time to calcify and harden. So I could have plaque, it’s just soft and not calcified.

Fast forward to present day and after once again getting back some cholesterol numbers that were “high”, my good buddy Dr. Tommy Wood told me about a new technology company called Cleerly Health that could take data from a coronary CT angiogram (which could detect both hard and soft plaque) and would do some additional analysis allowing you to see exactly where and how much of the plaque there is if any.

I decided to have a Cleerly scan done to get a more complete picture of where I stand at the age of 39 with regards to plaque. At least I would know if I have anything to be concerned about now at 39 and better inform my decision of how to move forward.

The coronary CT angiogram involves getting a dye injected into your arm and then having a CT scan of the heart done to get very detailed images of the main arteries of the heart. After getting the coronary CT angiogram done and Cleerly doing the analysis it determined I have no soft or hard plaque in any of my arteries!

WOOHOOO!

Below are the results and images from the Cleerly analysis.

The cardiologist that reviewed the results with me said it’s the first time he has seen zero plaque across the board after reviewing the data from several hundred patients (of course his dataset will be skewed towards people who are more likely to have heart disease).

TLDR: I have no signs of cardiovascular disease.

The question now becomes what do I do moving forward?

Do I keep on doing what I have been doing because it has been working, or do I still try to lower my lipids?

The first question is what else can I do to lower my LDL and APOB naturally?

“Natural” Interventions

The biggest mover of cholesterol numbers is diet. The timeframe for the data points on my lipids from above includes many dietary tweaks. In 2016 I was hard core keto in a caloric deficit, but at the end of 2023 I was eating 400+ grams of carbs and in a surplus. Despite eating diets at the opposite end of the spectrum, one high fat and low in calories and one high carb high in calories, my lipids look relatively the same.

One thing that may be confounding my cholesterol numbers is my thyroid function.

Thyroid hormone is important for clearing cholesterol. Whenever I am low calorie my, like in 2016 doing keto, my thyroid hormone production is also low. During these periods my cholesterol can be even higher than normal. However even when I am in a caloric surplus and my throid numbers being more normal, like at the end of 2023, my cholesterol is still on the higher side. I can only imagine that for me avoiding a caloric deficit slightly improved lipid numbers because I have more thyroid hormone which is clearing more cholesterol from my blood.

Some people also observe higher lipid numbers based on their saturated fat intake. While I was keto in 2016 my saturated fat intake was likely high (I was not tracking my food intake as diligently back then). I was on the keto bandwagon and eating higher fat foods then. However over the past year my saturated fat intake has been hovering between 17g and 27g a day. It’s not super low but it is also not super high either.

For me however, even eating a lower fat diet does not really show a difference in my cholesterol numbers.

Could I potentially get my saturated fat intake lower?

Sure.

But in order to do that I am going to remove foods like red meat, and skin-on chicken from my diet. The downside of doing that is that I will enjoy my diet much less, but more importantly I will be removing foods that have other beneficial nutrients that are hard to get from other foods.

The tradeoff likely isn’t worth it in my opinion.

Since diet manipulation doesn’t seem to make a difference in my blood lipids I decided to see if adding in some supplements could help.

There were two interventions I tried, supplementing with psyllium husk fiber and taking Red Yeast Rice Extract.

Psyllium husk fiber has been shown to lower cholesterol by binding up bile acids which reduces cholesterol absorption (Van Rosendaal, n.d.).

Red Rice Yeast Extract has also been shown to lower cholesterol and is often referred to as “nature’s statin”. Red Rice Yeast Extract contains a compound called monacolin K which inhibits an enzyme in the liver resulting in lower production of cholesterol by the body. This is exactly how statins work (Red Yeast Rice for the Improvement of Lipid Profiles in Mild-To-Moderate Hypercholesterolemia: A Narrative Review, 2023).

Unfortunately taking psyllium husk fiber caused me a bunch of stomach upset. I even tried cutting the dose in half and it still wasn’t pleasant. However, my diet is already high in fiber, I eat over 30 grams of fiber a day from fruits and vegetables. Adding more fiber via supplementation wasn’t going to make a massive difference.

I can’t come up with a reason as to why red rice yeast extract had no effect for me but after taking it for several months I didn’t see any movement in my cholesterol numbers.

From my point of view there is not much I haven’t tried from a diet or supplement perspective that will move the needle on my cholesterol.

My gut feeling after all this is that there is a strong genetic component at play here.

The first thing that comes to mind when talking about genetics and cholesterol is a genetic disorder called familial hypercholesterolemia. In this genetic disorder we usually see very high levels of LDL upwards of more than 190 mg/dl in adults. While I have had some blood tests where my LDL was above 190 mg/dl most of them have been below that threshold. In addition, my 23andMe genetic results say that all the 24 genes they tested for familial hypercholesterolemia are negative.

At the same time there are many more genes related to familial hypercholesterolemia that 23andMe does not test so there is still a possibility.

Maybe I don’t have hypercholesterolemia, but maybe there is some other kind of genetic variant at play that is causing my higher than normal cholesterol.

If I am doing everything I can feasibly do from a lifestyle perspective (without sacrificing other aspects of my lifestyle that may negatively impact my reasonable enjoyment of life) to bring my cholesterol down, what should I do about it?

Do I just not worry about it?

Do I look into pharmaceutical approaches to lower it?

Does my cholesterol numbers even matter if my lifestyle is good and I am healthy otherwise?

I don’t know the answer to the last question and I don’t think anyone knows with 100% certainty that your cholesterol numbers do not matter. However there is some scientific research that is starting to emerge on high cholesterol in otherwise healthy individuals that does seem to suggest that you might not need to worry as much about your cholesterol if you are healthy. So far the results are looking promising in that the development of heart disease doesn’t appear to be occurring. But even the researchers who have run these studies caution in the fact that you should not interpret these results as meaning high cholesterol is not potentially bad for your health.

At best some of this newest research is showing that maybe not everyone is susceptible to cholesterol causing cardiovascular disease.

How do we know who is susceptible and who isn’t?

Again we don’t have the answers to that question. We know some lifestyle factors will make it more likely that high cholesterol will cause cardiovascular disease, but we don’t know all the answers.

What have I decided to do based on where I stand today?

I would rather know that I tried every option feasibly available to me to make sure I minimize my risk of all health conditions. That includes pharmaceutical options.

For me, I am willing to try a small dose of a statin to see what happens.

If a small dose of statin lowers my LDL and APOB AND I don’t have any negative side effects from taking it, I think I am willing to go that route. It is kind of like an insurance policy because I don’t know that high cholesterol won’t promote heart disease IN ME. So if I can lower my cholesterol by optimizing my lifestyle AND a small pharmaceutical intervention, and have zero side effects of doing so I will personally feel more comfortable with that moving forward.

I plan on taking the statin for 3 months and getting my blood work done to see what effect it had on my cholesterol and other markers that statins can impact (to make sure there are no other negative side effects). I will obviously be paying attention to how I feel, and look for any side effects on my life as well.

Changes After 3 Months Of Taking A Statin

After taking 5mg of Rosuvastatin for 3 months I had my blood work done. Below are the results compared to my baseline.

Marker	Baseline	3 Months Of Statin
Total Cholesterol	280 mg/dl	203 mg/dl
LDL Cholesterol	197 mg/dl	116 mg/dl
HDL Cholesterol	66 mg/dl	73 mg/dl
Triglycerides	70 mg/dl	50 mg/dl
APOB	123 mg/dl	88 mg/dl

That was a great improvement!

I had no subjective side effects from taking the statin. My athletic performance was just as good. My strength was good and my aerobic performance was great. I managed to hit multiple strength and aerobic PRs while taking the statin. I have no signs of inflammation, my blood sugar numbers continue to look good, and liver enzyme numbers look “normal” for me.

Everything looked good taking a very small dose of a statin. However I would like to see my LDL and APOB numbers a little lower.

I had 2 options.

The first would be to increase the dosage of my statin to 10 mg or I could try another pharmaceutical intervention called Ezetimibe.

Ezetimibe works differently than a statin. Statins block the production of cholesterol in the live. Ezetimibe works by blocking cholesterol absorption from food. I decided to give Ezetimibe a try and do another blood test in 4 months.

Changes After 4 Months Of Adding Ezetimibe

After taking both the statin and Ezetimibe I got another blood test. Below are the results

Marker	Baseline	3 Months Of Statin	4 Months Of Stain + Ezetimibe
Total Cholesterol	280 mg/dl	203 mg/dl	139 mg/dl
LDL Cholesterol	197 mg/dl	116 mg/dl	44 mg/dl
HDL Cholesterol	66 mg/dl	73 mg/dl	81 mg/dl
Triglycerides	70 mg/dl	50 mg/dl	56 mg/dl
APOB	123 mg/dl	88 mg/dl	45 mg/dl

As you can see the combination of a statin and Ezetimibe had a massive impact on lipid numbers. No one could argue that these numbers look really good. Again my blood sugar, inflammation, and liver enzymes remained unchanged. And again my athletic performance and strength all continued to improve. So both objectively and subjectively I didn’t have any negative impacts from taking the statin and Ezetimibe.

What comes next?

For now I am going to continue taking 5 mg of rosuvastatin and 10 mg of Ezetimibe and see if my lipid numbers and other blood markers continue to stay at these new low levels. I may at some point stop the statin and see if Ezetimibe alone will keep my numbers this low. I obviously want to take as little pharmaceuticals as possible so if I can just take Ezetimibe then that seems optimal to me.

If however taking the Ezetimibe alone is not as effective as I want it to be and I need to add back in the statin I will happily do so. For me I have not seen any downside to taking a small dose of both drugs. If it does turn out that higher cholesterol are problematic even for individuals who are otherwise healthy, I at least know I have done everything I could to get my cholesterol numbers lower.

In 2016 when I was on the keto bandwagon I would have said my cholesterol numbers don’t matter and as long as I am healthy I am not worried. Now though I think there is likely more nuance to this discussion.

This is just one example of how we should not be married to our beliefs.

There does not appear to be any certainties when it comes to health, you can always find an individual that proves the prevailing narrative to be wrong. Ultimately you need to be open to changing your beliefs and practices based on the information you have.

This is why I share my personal journey with health from time to time on this blog.

I am not an expert, far from it, and I am always trying to learn to better inform the decisions I make. I have changed my opinion on a lot of things related to health since I began paying serious attention to it in 2016, and I am sure I will change my mind many more times as I move forward. As I learn more about what works and doesn’t work I will continue to share it with you with the content I produce. If you would like to continue with me on this never ending journey of health and wellness, be sure to sign up for my newsletter so I can share everything I learn with you! All you have to do is enter your email in the form below.

References

Berglund, L. (2016, July). Lipoprotein (a): impact by ethnicity and environmental and medical conditions. Retrieved 9 3, 2024, from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4918859/

Red Yeast Rice for the Improvement of Lipid Profiles in Mild-to-Moderate Hypercholesterolemia: A Narrative Review. (2023, May 12). PubMed. Retrieved September 3, 2024, from https://pubmed.ncbi.nlm.nih.gov/37242171/

Van Rosendaal, G. M. (n.d.). Effect of time of administration on cholesterol-lowering by psyllium: a randomized cross-over study in normocholesterolemic or slightly hypercholesterolemic subjects. NCBI. Retrieved September 3, 2024, from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC522822/