Since the Seven Countries Study, dietary cholesterol and the levels of serum cholesterol in relation to the development of chronic diseases have been somewhat demonised.

However, the principles of the Mediterranean diet and relevant data linked to the examples of people living in the five blue zones demonstrate that the key to longevity, and the prevention of chronic disease development is not the reduction of dietary or serum cholesterol but the control of systemic inflammation.

Cholesterol levels: Demonising a risk factor but not the causative mechanisms of chronic diseases

According to the "cholesterol hypothesis", high blood cholesterol is a major risk factor, while lowering cholesterol levels can reduce risk. Dyslipidaemias (i.e., hypercholesterolaemia or hyperlipidaemia) are abnormalities of lipid metabolism characterised by increased circulating levels of serum total cholesterol, LDL cholesterol, triglycerides, and decreased levels of serum HDL cholesterol.

High levels of LDL cholesterol and non-HDL cholesterol have been associated with cardiovascular risk, while other cholesterol-related serum markers have been proposed as additional significant biomarkers for CVD risk factors to add to the standard lipid profile. HDL cholesterol has been considered as the atheroprotective "good" cholesterol because of its strong inverse correlation with the progression of CVD.

Dyslipidaemias have been ranked as significant modifiable risk factors contributing to prevalence and severity of several chronic diseases including aging, hypertension, diabetes, and CVD. High serum levels of these lipids have been associated with an increased risk of developing atherosclerosis.

Dietary and medical guidelines (i.e. use of statins) have focused on the reduction of cholesterol and lipid levels as the best way to prevent chronic diseases such as CVD. Statins are used in order to reduce the levels of cholesterol; however, numerous side effects have been reported, including the development of other chronic diseases such as diabetes mellitus.

Moreover, specific dietary strategies for reducing cholesterol intake are the mainstay of management in most cases of dyslipidaemia, prior to, or simultaneously with, the initiation of a lipid lowering agent. Dietary fats, cholesterol, and the levels of serum cholesterol in relation to the development of CVD have been somewhat demonised.

Revisiting the lipid hypothesis

Today, there is a plethora of scientific evidence supporting that inflammation, not cholesterol is a cause of CVD and chronic disease. Therefore, we suggest that we need to re-evaluate our medical and dietary guidelines. We need to remember that Nature has provided us with a wide range of dietary weapons, which, if appropriately combined in dietary patterns such as the Med-diet, can beneficially contribute to improving our quality of life, health, and life expectancy by equilibrating the inflammatory milieu to normal levels and thus preventively reducing the risk of inflammation-related chronic disorders.

Let us not forget the words of Hippocrates of Kos (460-377 BC), who is universally recognised as the father of modern medicine, "Let food be thy medicine and medicine be thy food".

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