High Cholesterol

Cholesterol combines with two types of proteins in the blood. Depending on the type of protein that cholesterol binds to, there are three types of cholesterol that circulate in the blood.

• High-density lipoprotein cholesterol or HDL is known as ‘good’ cholesterol because it eliminates cholesterol from the blood by carrying its additional quantity from the blood to the liver for removal. HDL protects the heart from diseases such as atherosclerosis.
• Low-density lipoprotein cholesterol or LDL is commonly known as ‘bad’ cholesterol. It helps in the repair of damaged cells and has a tendency to deposit in the inner walls of blood vessels.
• Very low-density lipoprotein cholesterol or VLDL is also known as ‘bad’ cholesterol as an excess amount is also responsible for causing diseases of the heart and blood.

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High cholesterol does not produce symptoms by itself, but, when there are high cholesterol levels in the blood for a long period of time, they increase the risk of heart diseases. Some signs of high cholesterol levels which are picked up by the doctor on examination include:

• Xanthoma
  This is a collection of fat in the nodular form commonly seen on the eyelids, back, neck, or on the internal organs such as the stomach. Presence of xanthoma usually suggests a disturbance in fat metabolism.
• Corneal arcus
  It is a ring of fat in the transparent layer (cornea) of either a single eye or both the eyes. It is generally seen in elderly people who have long-standing high blood cholesterol levels.

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Heart problems related to high cholesterol levels include:

• Plaque
  Almost 75% of cholesterol is carried by LDL for use to different organs. The liver removes LDL either for reuse or for removal from the body. When the LDL level is high, the liver is unable to remove it from the body completely. As a result, it deposits in the walls of blood vessels and leads to the development of plaque. A plaque consists of a combination of fat (lipids), cholesterol, calcium, and other substances in the blood. It creates resistance to the blood flow due to narrowing of the passage of blood in the arteries.
• Carotid artery disease
  Plaque(s) can develop within the walls of the carotid arteries which supply blood chiefly to the brain. Insufficient blood supply to the brain due to plaque formation can cause stroke and affect areas of the brain that carry out different functions. After a stroke, loss of speech, and paralysis of one side of the body are common. A stroke can also occur when a piece of plaque gets detached and travels in the blood (embolus). It gets stuck in one of the smaller arteries in the brain and blocks the blood supply.
• Coronary artery disease
  Diseases such as the coronary heart disease cause angina or chest pain and heart attack due to atherosclerosis and plaque deposition in the arteries supplying blood to the heart. An embolus or a piece of plaque travelling in the blood can block small blood vessels and stop the blood supply to the heart or lungs (causing pulmonary embolism).
• Peripheral artery disease
  A peripheral artery disease results from a decrease in the blood flow chiefly in the legs (can also occur in the hands, stomach and kidneys). Insufficient blood flow in the legs results in pain and infection. In severe cases, it can cause cell death in the leg which might have to be removed surgically (amputated).
• Stroke
  It is a condition in which the supply of blood and consequently the oxygen is blocked to a part of the brain. Stroke is an emergency condition as the brain cells start dying after a few minutes of lack of oxygen. A stroke can also occur due to bleeding in a particular portion of the brain. A stroke results in permanent brain damage and long-lasting disability or death.

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Causes

The main causes for the development of high cholesterol levels are as follows:

• Unhealthy diet
  • Diet rich in saturated fats increase the LDL level in the blood. Meat, dairy products, egg, coconut oil, palm oil, butter, chocolates, deep-fried food, processed food and bakery products.
  • High intake of trans fats (made by hardening vegetable oil) in fried food and processed food items also increase the LDL level.
• Sedentary lifestyle
  An absence of physical activity in everyday life builds up LDL level in the blood and decreases the protective effect of HDL. In addition, obesity disturbs the circulation of fats in the blood.
• Smoking
  Smoking for a long period of time causes hardening of the blood vessels, raises blood pressure, increases the oxygen requirement of the heart, and leads to a disorder in fat metabolism by reducing the HDL level in the blood. All these factors eventually contribute to the diseases of the heart and blood vessels.
• Other diseases
  Some diseases also cause an increase in cholesterol levels in the blood. These include:
  • Polycystic ovarian disease (PCOD).
  • Hypothyroidism.
  • Diabetes.
  • Chronic kidney disease.
  • HIV.
  • Autoimmune disorders such as rheumatoid arthritis, lichen planus, and psoriasis among others.

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Risk factors

There are many factors that increase the risk of high cholesterol levels in the body.

Obesity, lack of physical activity, excessive fat in the diet, and cigarette smoking are the key avoidable risk factors that lead to the development of high blood cholesterol in the younger population. However, there are a few risk factors which cannot be avoided. These include:

• Age
  Fat metabolism undergoes changes with age. Compared to young individuals, the liver becomes slow or inefficient in removing LDL in elderly people. This increases the risk of high cholesterol in elderly persons.
• Genes
  A genetic defect can cause a disorder in fat metabolism and increase the level of cholesterol in the blood. Individuals with a family history of such genetic defects are at a high risk of developing high blood cholesterol. Also, people whose family members have suffered from a stroke or heart attack before the age of 55 years or between 55 and  65 years of age, come under the high-risk category.
• Gender
  Men are likely to suffer more from high cholesterol and cardiovascular diseases than women.
• Other diseases
  There is a strong association between diabetes mellitus and high cholesterol and cardiovascular diseases.

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With a few exceptions related to hereditary (genetic) causes and old age, high cholesterol can be prevented in many cases by following these tips:

• Eat a heart-healthy diet
  Diet is the most important factor that can help prevent the increase in cholesterol levels in the blood. Avoid excessive use of saturated fat-rich food items in the diet. Such food items include meat, eggs, fried and processed food, and dairy products.
• Include more fresh fruits, vegetables, and salads in the diet
  Modify your dietary habits. For example, use low-fat or skimmed milk instead of whole milk, or make use of vegetable oils for cooking. Include whole grains, fish, nuts and chicken in the diet. Restrict the use of sugary food and drinks and incorporate high fibre in the diet.
• Stay active throughout the day
  A sedentary life with a lack of physical activity lowers the HDL level in the blood.
  Moderate aerobic exercises for minimum 45 minutes three to four times in a week help to keep cholesterol levels in check. Brisk walking, running, swimming, and dancing are some examples of aerobic exercises.
• Maintain an ideal weight
  Being overweight or obese increases the LDL level and decreases HDL in the blood. Losing weight contributes to a great extent in reducing the high level of cholesterol.
• Quit smoking
  Smoking disturbs fat metabolism and lowers HDL levels in the blood. Smoking, along with, high cholesterol increases the risk of heart diseases, high blood pressure, and diabetes.

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Doctors diagnose high cholesterol on the basis of physical examination, detailed family history, diet and lifestyle habits, previous history of high blood pressure, heart attack and stroke.

• Clinical signs
  Presence of xanthomas or corneal arcus are the signs that help doctors in diagnosing high cholesterol before advising a blood test.
• Blood tests
  • Blood tests such as lipid profile help in confirming the diagnosis of high cholesterol. Lipid profile measures levels of total cholesterol, high-density lipoprotein (HDL), low-density lipoprotein (LDL) or non-high density lipoprotein. High cholesterol is diagnosed when the level of LDL and VLDL is higher than the normal range for the age and gender of the patient.
  • Total cholesterol level of more than 200 mg/dL is beyond the normal range (200-239mg/dL is borderline high and 240 mg/dL is high)
  • LDL more than 100mg/dL is above the normal range (130-159mg/dL is borderline high, 160-189mg/dL is high and 190mg/dL and above is very high)
  • HDL level of 60mg/dL and above is protective for the heart (less than 40mg/dL increases risk of heart diseases).
• Other tests
  Doctors may advise other tests to rule out the diagnosis of other diseases. These include:
  • Ultrasound test for the polycystic ovarian disease.
  • Blood tests for thyroid hormone (hypothyroidism).
  • Tests to rule out autoimmune conditions like rheumatoid arthritis, psoriasis and more.

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Medicines are essential to reduce the level of raised cholesterol in the following situations:

• When lifestyle and dietary modifications are not sufficient to lower high cholesterol levels.
• A history of heart attack.
• High levels of bad cholesterol (LDL).
• People between 40-75 years age group with high risk of heart diseases.
• People with diabetes or other heart diseases.

Different types of medicines are used to decrease the raised cholesterol levels in the blood. Your doctor will decide the suitable medicine for you on the basis of age, current health condition, the risk of developing heart diseases or stroke. Medications include:

• Statins are most commonly used to decrease the high cholesterol level. Statins block the production of cholesterol in the liver.
• PCSK9 (Proprotein convertase subtilisin/kexin type 9) inhibitors are the medicines that act on the liver and help it to remove LDL from the blood. They also help in decreasing triglycerides in the blood.
• Bile acid sequestrants decrease blood cholesterol level by their action on bile acids.
• Niacin (vitamin B3 or nicotinic acid) decreases LDL (bad cholesterol) and increases HDL (good cholesterol).
• Fibrates remove very low-density lipoprotein (VLDL) from the blood. They also increase the HDL level. However, when used with statins, fibrates can cause problems related to the muscles.
• Ezetimibe prevents the absorption of cholesterol from food.
• Lomitapide and mipomersen prevent the secretion of VLDL cholesterol from the liver in the blood. It is commonly used in patients who have a high level of cholesterol due to the inherited genes.
• Lipoprotein apheresis is a process in which excess of bad cholesterol is removed from the blood using a filtering machine placed outside the body. This is commonly used in patients with an inherited disorder leading to a high cholesterol.

Lifestyle management

Lifestyle modification plays an important role in the management of high cholesterol. Here are some important lifestyle modifications that can keep your cholesterol in check.

• Dietary changes
  • A concept called therapeutic lifestyle changes is helpful in decreasing bad cholesterol in the blood. According to this diet plan, these dietary tips need to be followed:
  • Saturated fats (meat, dairy products, deep-fried food among others) should meet 7% of your daily calorie needs and total fats altogether should provide a maximum of 35% of your daily calorie requirement.
  • Up to 200mg of cholesterol can be consumed daily.
  • Diet should be rich in soluble fibres that include whole grains, fruits and legumes (example: oats, apples, bananas, pears, oranges, kidney beans, lentils, chickpeas). Soluble fibers in vegetables and fruits prevent absorption of cholesterol.
  • Fish is a rich source of omega-3 fatty acids which protects from heart diseases and heart attack.
  • Salt restriction and limiting alcohol intake helps in controlling blood pressure and triglycerides in the blood.
• Physical activity
  Regular aerobic exercises help in reducing high cholesterol and also in the management of obesity.
• No smoking
  Stop smoking completely for effective management of cholesterol.
• Use of Medicines
  Continue with the medicines prescribed by the doctor for the effective control of cholesterol to bring it within the normal limits.
• Foods for lowering cholesterol
  Some foods that help in keeping the cholesterol level in check include oats, barley, beans (kidney beans, chickpeas, lentils.), eggplant, okra (lady finger), nuts (almonds, walnuts, peanuts), vegetable oil (sunflower oil, safflower oil), fruits (citrus fruits, apples, grapes), foods containing sterols and stanols (plant gums that absorb cholesterol from food), soy (tofu, soy milk), fish (salmon, mackerel), fibre supplements found in laxatives.

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Prognosis

It is important to remember that medicines control the level of cholesterol, but, do not cure it. The outcome depends on various factors. Early detection of high cholesterol helps in timely treatment and management. Advancing age decreases the chances of maintaining cholesterol level in a healthy range. The outcome is poor when the causes and risk factors (overweight, fat-rich diet, lack of exercise, smoking) of high cholesterol are not considered or prevented for effective management of high cholesterol.

Complications

High levels of cholesterol, when left untreated for a long time, cause life-threatening conditions such as angina, heart disease (coronary heart disease, angina, heart attack), and diseases of blood circulation (stroke, peripheral vascular disease, carotid artery disease).

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High cholesterol levels are a significant health problem as they increase the risk of various diseases especially those related to the heart and blood circulation. Increased blood cholesterol levels increase the risk of heart attack or chest pain as well as conditions related to blood circulation in the brain such as stroke. Studies report that in India, 25% to 30% of the urban and suburban population have higher levels of blood cholesterol compared to the rural population, which is 15% to 20%. Borderline high LDL, a low HDL, and a high value of triglycerides are frequently noted in the Indian population.

What is cholesterol?

Cholesterol is a fatty wax-like substance produced in the liver. Since it does not dissolve in water, cholesterol binds itself mainly to fats (known as lipids) and proteins, which are collectively known as lipoproteins. Cholesterol is necessary for performing many essential functions in the body such as the production of hormones, vitamin D, absorption of fat-soluble vitamins such as vitamin A, D, E and K, and formation and maintenance of the cell structure. However, when cholesterol levels exceed the normal range in the blood, it can lead to heart diseases, heart attack and stroke. Also, this excessive cholesterol then binds with different substances (such as calcium) to form plaques (fatty deposits) in the blood vessels and making them hard (atherosclerosis). This leads to problems in the flow of blood resulting in insufficient blood supply to the different body organs.