Is High Cholesterol the Real Cause of Heart Disease? A Functional Medicine View

By Dr. John Bartemus, DC, CFMP, Functional Medicine Charlotte, PC. Last updated June 19, 2026.

For decades the message was simple: cholesterol is high, so lower the cholesterol. That message is not wrong so much as incomplete. The biology of heart disease is more nuanced, and treating a single number can miss the factors that actually damage arteries. Here is a fuller picture.

What cholesterol actually does

Cholesterol is not a toxin. It is found in every cell, and your body uses it to build cell membranes, produce vitamin D, manufacture hormones, and support healthy brain function. It travels through the blood in particles called lipoproteins. HDL (“good” cholesterol) helps remove excess cholesterol from arteries. LDL (“bad” cholesterol) can deposit in arterial walls and contribute to plaque. Triglycerides, a separate blood fat, rise with excess sugar and refined carbohydrate intake and are independently linked to heart disease and diabetes.

Why total cholesterol is a weak predictor

Total cholesterol on its own tells you very little. Two details matter far more. First, ratios: the triglyceride-to-HDL ratio and the total-cholesterol-to-HDL ratio track metabolic health better than any single value. Second, particle size. LDL comes in large, buoyant particles that are relatively harmless and small, dense particles that more easily lodge in arterial walls and drive inflammation. Two people with identical LDL numbers can have very different risk depending on particle type.

This is why a UCLA analysis of nearly 137,000 patients hospitalized for a heart attack is so often cited: roughly 72 percent had LDL below the standard target at admission. Here honesty matters. Functional medicine reads this as evidence that cholesterol alone does not explain heart attacks. Mainstream cardiology reads the same data differently, arguing the targets were simply too lax and that LDL should be pushed lower. Both interpretations come from the same numbers. The reasonable takeaway is that LDL is one input among several, not a standalone verdict.

The inflammation piece

Here is the model that makes sense of the data. Inflammation damages the lining of arteries. The body uses cholesterol to patch that damage, and over time these patches become plaque. In this view, cholesterol is more like the repair crew at the scene of the accident than the cause of the crash. The accident is inflammation.

This is measurable. High sensitivity C-reactive protein (hsCRP) is a blood marker of systemic inflammation, and elevated hsCRP is associated with higher cardiovascular risk even when cholesterol is normal. Sources of chronic inflammation include a diet high in sugar and processed carbohydrates, insulin resistance, smoking, chronic stress, poor sleep, gut problems such as leaky gut, low thyroid function, and unmanaged autoimmunity. Hydration even plays a supporting role in cardiovascular load, which I covered in this article on daily water intake.

Carbohydrates, not dietary fat, drive much of the problem

The low-fat, high-carbohydrate advice promoted for decades has not produced the heart health it promised. Sugar and refined carbohydrates lower HDL, raise triglycerides, and shift LDL toward the small, dense, dangerous particles. They also drive insulin resistance, which is itself a major cardiovascular risk factor. The evidence on saturated fat has also softened: several meta-analyses have not found a clear link between saturated fat intake and heart disease, though this remains debated and individual responses vary. Some people, including certain ApoE4 carriers, do see a sharp LDL rise on high saturated fat and may benefit from moderating it. The honest summary: dietary fat is not the villain it was made out to be, refined carbohydrates deserve more scrutiny than they get, and the right diet is individual.

What about statins?

Statins lower LDL effectively, and for people who have already had a heart attack or who are at high calculated risk, the evidence for benefit is reasonably strong. That deserves to be said plainly. At the same time, statins carry tradeoffs that warrant an honest conversation with your doctor.

One is diabetes risk. Randomized trials show statins modestly increase the risk of developing type 2 diabetes, roughly 10 to 12 percent overall and up to about 36 percent with high-intensity dosing. The FDA added a label warning to this effect in 2012. Other reported side effects include muscle aches and weakness, and because cholesterol supports brain and hormone function, some people are sensitive to having it driven very low. Mainstream cardiology generally concludes that for higher-risk patients the cardiovascular benefit outweighs the diabetes risk. For lower-risk patients using statins purely for primary prevention, the calculus is less clear cut and more individual. The point is not “never take a statin.” The point is that this should be a genuine risk-benefit decision, not an automatic one. Never start or stop a statin without your prescribing clinician.

A functional medicine approach to heart health

Rather than treating a number, functional medicine works to identify and address what is driving your risk. In practice that looks like:

• An anti-inflammatory, whole-foods diet that limits sugar and refined carbohydrates and includes healthy fats.
• Regular exercise, which lowers triglycerides, improves insulin sensitivity, and reduces inflammation.
• Better testing: triglyceride-to-HDL ratio, non-HDL cholesterol, LDL particle number and size, Apolipoprotein B, Lp(a), fasting insulin and glucose, and hsCRP.
• Finding hidden drivers of inflammation: blood sugar dysregulation, low thyroid function, autoimmune disease, chronic infections, leaky gut, and chronic stress.
• Sleep and stress management, both of which directly affect inflammation and blood sugar.

For people with a genuine genetic disorder such as familial hypercholesterolemia or very high Lp(a), diet and lifestyle may not be enough, and medication can be appropriate. The goal is the right tool for the right person, based on a full picture rather than a single value.

The bottom line

High cholesterol is a signal worth understanding, not a verdict to fear. Ask for the markers that actually reflect your metabolic health and inflammation, address the root causes that damage arteries, and make any medication decision as an informed risk-benefit choice with your clinician. Treating the cause beats chasing a number.

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Frequently asked questions

Is high cholesterol the cause of heart disease?

High cholesterol is one risk factor, not the sole cause. Chronic inflammation, insulin resistance, high triglycerides, small dense LDL particles, and elevated Lp(a) often predict cardiovascular risk better than total cholesterol alone. In a UCLA analysis of heart attack patients, about 72 percent had LDL below the standard target.

Do statins cause diabetes?

Statins modestly raise the risk of type 2 diabetes, roughly 10 to 12 percent in trials and up to about 36 percent with high-intensity dosing. The FDA added a label warning in 2012. For many higher-risk patients, cardiologists conclude the cardiovascular benefit still outweighs this risk. The decision is individual and belongs with your prescribing clinician.

What markers matter more than total cholesterol?

The triglyceride-to-HDL ratio, non-HDL cholesterol, LDL particle number and size, Lp(a), Apolipoprotein B (apoB), fasting insulin and glucose, and high sensitivity C-reactive protein (hsCRP). These reflect metabolic health and inflammation, which drive arterial damage.

How can I lower cardiovascular risk without medication?

Reduce refined carbohydrates and sugar, prioritize whole foods and healthy fats, exercise, improve sleep, manage stress, and identify hidden drivers of inflammation such as poor blood sugar control, thyroid dysfunction, or gut problems. Do not stop prescribed medication without medical supervision.

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About the author: Dr. John Bartemus, DC, CFMP, is a functional medicine practitioner, educator, speaker, and Amazon international number one best-selling author specializing in optimizing health through Functional Medicine Charlotte, PC.

This article is for educational purposes only and is not medical advice. It is not a recommendation to start, stop, or change any medication. Cardiovascular disease is serious; discuss your individual risk and treatment with a qualified clinician.