This is probably the most recent study to look into the role of Cholesterol.
One thing to mention first, is that this comes out of Sweden, where opinions regarding the relative importance of fats and carbs are slightly more progressive, with the Swedish Council on Health and Technology recommending a diet low in Carbs (for those with diabetes or obesity) as far back as 2015, though the general guidelines are in line with other Nordic countries and more broadly.
So - a very comprehensive study which sets out to ask "what?" rather than try to confirm the role of cholesterol in coronary atherosclerosis.
In other words - not "can we prove that this happens" but - lets measure as many health markers as we can and see which shows the best indication for risk of heart disease.
The full title is:
Lipoproteins and lipoprotein lipid composition are associated with stages of dysglycemia and subclinical coronary atherosclerosis
Published in the International Journal of Cardiology and only publicly available at the end of last year.
From the abstract: "We aimed to identify a dyslipidemic profile associated with both dysglycemia and subclinical coronary atherosclerosis."
In more simple terms, can we look at blood lipid panel and identify the health markers that best show risk for poor blood glucose control and development of heart disease?
The report itself is well worth the read, but it's reasonably hard going.
One of the big issues with all of this is the tendency we all have to fall into competing camps, and I like this work because it doesn't do that at all. There is a complicated relationship between glucose and fats, and it doesn't benefit anyone to make the argument that it's either all one thing or the other. Beyond that, the way that individuals process both can be uniquely different, so trying to better understand the way that all the details interact is going to be more useful for everyone - at least in my opinion. This work seems to be trying to do that - not starting from a stated belief and trying to maintain it, which is what so many studies fall foul of.
Statistically, the biggest risk for anyone diagnosed with Diabetes of any type, is developing one of the end results of plaque build-up, and this is why it's so important. I think that is self-evident.
However - dyslipidaemia simply means "something wrong in the composition of all the fats in your body" - not "too much cholesterol" - and I'm in full support of any work that tries to figure out what it is that is actually going wrong.
A large group of random Swedes were split into (
my words) normal/ pre-diabetic /diabetic and a whole bunch of measurements and complicated maths done to ensure statistical fairness.
I would encourage anyone interested to read the study;
My interpretation of the results (only my interpretation, and no more valuable than anyone else's)
1 - All of the blood glucose markers are as expected, raising from normal -> diabetic
2 - The CAC (measurement of artery calcification) also tracked with this trend, ie, more the further toward diabetic.
3 - The LDL levels were
reversed. Ie, the worse the health, the lower the LDL and total cholesterol.
In other words - simply looking at these results - you could only infer that raising your LDL was preferrable for heart health. (
this is just an aside - the study does not, nor do I, claim this.)
4 - lower HDL and higher Triglycerides also followed the "worsening health" trend, which is in line with the metabolic syndrome perspective, (not sure about blood pressure).
5 - The size and distribution of lipoprotein particles, LDL and HDL (actually all of them, if you understand that most fat-carrying particles start off as VLDL and progressively become LDL) really does matter. Just because I've said LDL isn't helpful the way we measure it, doesn't mean it's not important.
6 - the study concludes that statins may be helpful in reducing the % of small diameter HDL particles.
Some other key points:
This is paraphrasing, but insulin resistance changes everything - IR leads to increased triglyceride production in the liver. Among all the biomarkers - the quantity of triglycerides in the larger lipoproteins was the most statistically significant, and triglyceride composition in all types was important (ie, lower triglyceride is better).
Direct quote:
"Diabetes associated dyslipidemia is commonly defined by the presence of high triglycerides, low HDL, and elevated levels of small dense LDL"
Typically, the LDL levels in diabetics was lower, this was attributed to statin prescriptions which had that effect, but they absolutely conclude that for high-risk patients, the benefit of statins outweighs the risk (of directly developing diabetes). In other words, the study was not "anti-statin".
It's a fascinating study looking at the range of biomarkers in a contemporary population, compares mechanisms with several other large studies; Framingham, UK Biobank, China Biobank etc, but makes relatively few recommendations. I do think it's a useful guide for personal use - it gives you some insight as to what you might want to focus on given your own blood glucose level, insulin resistance and lipid panel.
I know the conclusions I draw for myself, and I have to admit that this muddies the water somewhat on the use of Statins more broadly. Overall, I think this just says "you know, it's more complicated"
