Title: Re-evaluating Cholesterol: The Myth, the Science, and the Truth Behind Coronary Heart Disease
By Dr. Lim Ju Boo and Prof. MC Sage
On Tuesday, August 17, 2021 I singly wrote an article entitled:
https://scientificlogic. blogspot.com/search?q=does+ cholesterol+cause+heart+ disease
Today, I am writing to answer this same question again, friends and the public asked over and over again.
This time I shall answer this age-old question again together with my senior most research partner Professor MC Sage.
It is very unfortunate the gullible public believe in everything their doctors tell them, example "cholesterol causes heart disease, and you need to take the medicine (statin) I shall prescribe for you"
Introduction
For decades, cholesterol has been demonized as the central villain in coronary heart disease. Public health campaigns, dietary guidelines, and medical prescriptions converged on a simple yet potent message: avoid cholesterol, reduce saturated fats, and lower your serum cholesterol to prevent heart attacks.
But is cholesterol truly the cause of heart disease? Or is this one of the most profound misinterpretations in medical history? This article seeks to re-examine this question with a critical lens, combining firsthand analytical experiences, historical reflections, and rigorous scientific studies.
The Early Narrative: Cholesterol and the Framingham Heart Study
The Framingham Heart Study (FHS), launched in 1948, was instrumental in shaping our understanding of cardiovascular risk factors. Early analyses of FHS data did indeed find a statistical correlation between high total serum cholesterol levels and increased risk of coronary heart disease, especially among middle-aged men.
This correlation catalyzed the diet-heart hypothesis, most famously championed by Ancel Keys, who postulated that saturated fat intake raised cholesterol, which in turn caused heart disease.
In parallel, massive public health policies were enacted. The American Heart Association, USDA, and global health bodies issued strong guidelines to reduce cholesterol and saturated fat intake.
The Shift in Understanding: Later Phases of FHS and Beyond
As FHS continued over multiple generations and decades, later findings began to challenge the initial conclusions:
Cholesterol levels were not predictive of heart disease in the elderly.
A significant number of patients who experienced myocardial infarctions had normal cholesterol levels.
Other factors emerged as stronger predictors: smoking, hypertension, diabetes, stress, sedentary lifestyle, and systemic inflammation.
In fact, Dr. William Castelli, a former director of the Framingham Study, famously stated:
"In Framingham, Mass, the more saturated fat one ate, the more cholesterol one ate, the more calories one ate, the lower the person's serum cholesterol... and the people who ate the most cholesterol, saturated fat and calories were the most physically active and weighed the least."
(Source: Archives of Internal Medicine, 1992)
This marked a significant reversal of the cholesterol narrative.
My Personal Professional Observations and Experience
As a Senior Medical Research Officer at the Institute for Medical Research (IMR), Malaysia (1968–1994), I had the privilege and responsibility of signing tens of thousands of diagnostic reports on serum cholesterol levels.
Blood samples arrived daily from government hospitals across the country, from Johor Bahru in the south to hospitals near the Thai border in the north, including East Malaysia.
Our lab technicians and analysts found no consistent correlation between cholesterol levels and the clinical notes provided by physicians. Patients suspected of ischemic heart disease, angina, or myocardial infarction often had normal cholesterol levels.
We reanalyzed samples to rule out analytical errors:
Repeated tests showed less than 1–2 mg/dL variation.
Spiking experiments using known cholesterol amounts confirmed our accuracy.
Cholesterol recovery analysis also validated our procedures.
We concluded the fault was neither with the patient nor the lab, but possibly with a flawed foundational theory still widely believed by clinicians.
Cholesterol: Biochemistry, Physiology, and Misconceptions
Cholesterol is not inherently harmful. It is a pale-yellow, waxy compound, essential for numerous physiological functions:
Cell membrane structure
Synthesis of steroid hormones (testosterone, estrogen, cortisol)
Vitamin D metabolism
Myelin sheath formation in nerves
The liver produces about 85% of the body’s cholesterol, tightly regulating blood levels through homeostatic feedback mechanisms.
Even consuming large quantities, e.g., 10 eggs a day (providing ~1860 mg cholesterol), barely shifts serum cholesterol, as the body adjusts endogenous production accordingly.
I have personally eaten two eggs daily for over 70 years and frequently consumed goat’s brain curry (high in cholesterol and choline) for 10 years, with no abnormal serum cholesterol nor any cardiovascular events.
Dietary Cholesterol: Revisions in Guidelines
The 2015 Dietary Guidelines for Americans (DGAC) officially removed cholesterol from the “nutrients of concern” list:
*"Available evidence shows no appreciable relationship between consumption of dietary cholesterol and serum cholesterol."
This marked a policy U-turn after decades of caution. Foods like eggs, butter, dairy, coconut oil, and liver were no longer demonized.
Even Dr. Steven Nissen, a renowned cardiologist, affirmed:
"We got the dietary guidelines wrong. They've been wrong for decades."
LDL, HDL, and Oxidation Theory
While LDL (Low-Density Lipoprotein) is labeled “bad” and HDL (High-Density Lipoprotein) “good,” this distinction is simplistic.
What makes LDL dangerous is oxidation:
Oxidized LDL becomes sticky and gummy, adhering to the damaged intima of arteries, forming plaques.
Free radicals, especially from stress, smoking, and poor diets, oxidize LDL, leading to atherogenesis.
Cholesterol itself, when pure, is neither sticky nor soluble in water. It requires lipoprotein carriers to travel in blood.
Stress, Inflammation, and the Real Culprits
Research increasingly points to inflammatory processes as the true cause of atherosclerosis, often initiated or aggravated by:
Chronic psychological stress
Elevated cortisol and adrenaline
Oxidative stress and free radical damage
Endothelial dysfunction
See this detailed article: "Why Reducing Stress is More Important Than Lowering Cholesterol" -
https://www.stress.org/why-reducing-stress-is-much-more-important-than-lowering-cholesterol
Statins and the Pharmaceutical Industry
By the time the Framingham Study began softening its stance on cholesterol, statins had already flooded the market.
Drugs like atorvastatin, simvastatin, lovastatin, etc., were producing billions in revenue.
In 2002 alone, statin prescriptions reached USD 88 million. Today, they yield nearly USD 60 billion annually.
While statins lower LDL and reduce cardiovascular events in high-risk populations, their over prescription in healthy individuals has drawn criticism.
The US government and medical research bodies were slow to update guidelines, possibly influenced by powerful pharmaceutical interests. Doctors rarely read primary literature and instead rely on pharma sales representatives.
Emerging Research: Beyond Cholesterol
Many modern studies support a more holistic approach:
Oxidative damage as the catalyst for plaque formation
Calcium buildup and osteoblastic cell differentiation in arterial walls (see Hyo-Soo Kim, Seoul National University)
Genetics, infections, gut microbiome, and dietary sugar play significant roles
Dr. John Yudkin (1910–1995), my former professor at Queen Elizabeth College, University of London, was one of the earliest to warn about sugar, not cholesterol. His book "Pure, White and Deadly" was prophetic, but dismissed at the time.
Supporting Literature & References
Conclusion
The once unchallenged view that cholesterol causes heart disease is now being re-evaluated. While cholesterol, particularly oxidized LDL, can contribute to atherosclerosis, it is not the primary cause.
The true culprits appear to be stress, inflammation, oxidative damage, dietary sugar, sedentary behavior, and poor lifestyle choices.
It is time the medical community reorients itself with updated science, reduces unnecessary prescriptions, and adopts a holistic model of cardiovascular care. The myth of cholesterol as the singular cause of heart disease must be laid to rest.
Signed with gratitude and scientific clarity,
Dr. Lim Ju Boo
Senior Medical Research Officer (Ret.)
Institute for Medical Research, Malaysia
Prof. MC Sage
Research Scholar and Scientific Partner