Cholesterol - The Good, The Bad and The Ugly

Welcome to Cell Systems. Today we are talking about cholesterol—everything you need to know, the myths we’re going to bust, and the good, the bad, and the ugly. We have a special guest, Dr. Abid Husain, a cardiologist practicing longevity and cellular medicine in Boulder, Colorado. Dr. Husain recently gave a talk at COMM regarding labs he wants to see when working up a patient.

Cholesterol is widely misunderstood. Historically, it has been associated with atherosclerotic heart disease and used to assess cardiac health, but in reality, it’s not the marker we should be looking at. What we need to examine are the types of cholesterol particles and the processes associated with them. Cholesterol itself is not necessarily the bad player; the particles are. High particle numbers are associated with atherosclerosis and higher cardiovascular issues, so we do have to be aware of them as they contribute to the disease.

The big difference is looking at cholesterol mass versus particle number. Most physicians look at an LDL or even just a total cholesterol, which is a mass number. We should be looking at ApoB, which measures the number of particles that are atherogenic. These particles are what insult the lining of the artery. Think of particles like bullets: they can be large and buoyant, like bean bags that don't penetrate, or they can be small and dense, like actual bullets.

Inflammation is another critical factor. Particles associated with inflammation become much more atherogenic. We also have to look at glucose metabolism and hepatic health because the liver makes these particles. If the liver isn’t healthy, it cranks out more atherogenic particles. A simple framework for assessment includes a CBC, a comprehensive metabolic panel, a lipid panel, and an ApoB. By looking at the LDL to ApoB ratio, if it's below 1.2, it suggests small, dense LDLs, which triggers questions about the liver and glucose metabolism.

Other essential markers include the triglyceride to HDL ratio, the AST to ALT ratio (to see if the liver has fatty deposition), and the neutrophil to lymphocyte ratio from a CBC. If neutrophils are elevated above 2.0 or 2.5, it tells us the innate immune system is activated, often even before hs-CRP is elevated. While industry focus remains on LDL because it was the only tool we had for a long time, the dialogue hasn't evolved to match our understanding of vascular and metabolic health.

Patients often view their LDL score as a report card or a "moral failure," but we have to take it into context with the entire patient. High cortisol or insulin resistance can be more concerning than LDL. Cholesterol is a beautiful molecule—it’s part of every cell wall and essential for making hormones. Dealing with it requires looking at the "terrain" it finds itself in. Some patients with unremarkable lipid panels still have events because of high homocysteine, high Lp(a), or chronic inflammation and stress.

A significant issue is that many patients are just "adapted" rather than asymptomatic. They may feel tired for years but don't realize it until after a cardiac event. This is why digging deeper into genetic markers and inflammation is vital. We should be telling a story with a patient's labs and focusing on trend improvements over time rather than single values. The human body and our food have changed since the 1970s, yet the standard assessment hasn't.

There is a lot of polarization in the medical community, with some doctors pushing high-dose statins and others saying cholesterol is great. The truth is in the middle. While we might overprescribe statins, some high-risk patients truly need them. However, we can get 80% to 90% of the information we need from basic panels if we look at ratios and context. If we wait for official guidelines to catch up to markers like ApoB, we will be a decade late.

Statins are the most prescribed drugs in the US, with Lipitor and Crestor reaching tens of millions of patients. While they have their place, they come with side effects like rhabdomyolysis (muscle pain), cognitive impairment, brain fog, and fatigue. A major concern is CoQ10 depletion, which is essential for mitochondrial function. If mitochondria are affected, everything downstream suffers. Most patients reporting muscle pain or fatigue are experiencing a direct relationship to CoQ10 deficiency.

The real problem isn't cholesterol; it's plaque. Humans are creatures of habit, and the association between cholesterol and heart disease is hardwired into doctors and the population. However, we now have technology like Cleerly—an AI-based platform that uses CT coronary angiograms to differentiate tissue density. This allows us to see if plaque is inflamed (soft) or calcified. This is a game-changer because it identifies those at risk for sudden heart attacks.

In a longevity practice, imaging should be upfront. Seeing the actual plaque directs how aggressive treatment needs to be. For example, hot, inflamed arteries need to be cooled quickly. This technology provides a visual diagram for patients, showing them exactly where their arteries are compromised, which helps with compliance for aggressive therapy and lifestyle changes.

Recent shifts, like the FDA removing the black box warning for testosterone regarding cardiovascular disease, show that science is moving, even if the guidelines are slow. We have to pivot faster as a profession. Adaptation can masquerade as health—feeling crummy for so long that it becomes your "normal." Patients need to be proactive and realize that one out of every two people will deal with some sort of heart issue. Understanding the next steps for your specific health and life is the best way to take action.