High Cholesterol / Hypercholesterolemia

Overview

High blood cholesterol level is one of the major risk factors for heart disease. If the cholesterol level is too high, it can be deposited in tissues, specifically, the arteries, causing them to narrow and not carry enough blood to vital organs such as the brain or the heart. High cholesterol levels also weaken the artery, causing it to enlarge and produce an aneurysm. This process is termed " atherosclerosis”.

What is Cholesterol?

The word ‘cholesterol’ comes from the Greek word ‘chole’, meaning ‘bile’ and ‘stereos’, meaning ‘solid.’ Cholesterol is a type of fat and is the vital building block of many substances including the cell membrane of every cell in the human body, some hormones and serves several body functions.

Cholesterol in a person's blood originates from two major sources, dietary intake and liver production. The liver produces about 80% of cholesterol present in the body and rest comes from dietary sources like meat, poultry, fish and dairy products. Organ meat such as liver are especially high in cholesterol content while foods of plant origin contain no cholesterol.

Dietary cholesterol is absorbed from the intestine and stored in the liver and adipose tissue secreted when it is needed by the body. After a meal, cholesterol is absorbed by the intestines into the blood circulation by getting packaged inside a protein coat. The bigger molecules are called chylomicrons and absorbed through the lymphatic system whereas the smaller molecules of fat get directly absorbed through the blood stream by combining with a protein and are called lipoprotein.

LDLs, HDLs and Your Heart

Cholesterol is carried in the blood as a package called lipoproteins. Like oil and water, cholesterol and blood do not mix. So, in order to pass through the bloodstream, the cholesterol made in the liver is also smeared with a layer of protein making a lipoprotein. This lipoprotein then carries the cholesterol through the bloodstream.

The density of lipoproteins varies and they are classified according to the density as Low-Density Lipoproteins (LDL) and High-Density Lipoproteins (HDL). As the density differs, the action of both differs.

Low-density lipoproteins (LDLs) carry most of the cholesterol in the blood and are also known as 'bad cholesterol' (for the sake of recollection one can remember the ‘L’ of LDL for ‘Lousy cholesterol’). The cholesterol and fat from LDLs are the main sources of cholesterol that accumulates and blocks the arteries of blood vessels. Thus, more the LDL-cholesterol in the blood, the greater the risk of heart disease.

High-density lipoproteins (HDLs) or the good cholesterol (for the sake of recollection one can remember the ‘H’ of HDL for ‘Healthy cholesterol’) carry some of the cholesterol in the blood, but this cholesterol goes back to the liver, which leads to its removal from the body. So HDL helps prevent cholesterol from building up in the walls of the arteries. If the level of good cholesterol or HDL is low, the risk of heart disease is greater.

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What Do The Cholesterol Numbers Mean?

People over the age of 19 years should have their cholesterol levels checked once in 5 years. Lipoprotein profile blood test can help one find out the cholesterol numbers. In cases where lipoprotein profile test is not possible, knowing the person’s total cholesterol and HDL cholesterol values can give a general idea about the cholesterol levels. Cholesterol levels are measured in milligrams (mg) of cholesterol per deciliter (dL) of blood.

Fasting blood sample to check your Lipid profile or Cholesterol levels - You should be fasting for 12 hours before you give a sample of your blood for checking the level of cholesterol and lipids in your blood sample.

Total Cholesterol Level	Category
Less than 200 mg/dL	Desirable
200-239 mg/dL	Borderline High
240 mg/dL and above	High

LDL Cholesterol Level	LDL-Cholesterol Category
Less than 100 mg/dL	Optimal
100-129 mg/dL	Near optimal/above optimal
130-159 mg/dL	Borderline high
160-189 mg/dL	High
190 mg/dL and above	Very high

HDL cholesterol also known as good cholesterol is found to have a protective effect on heart health. Hence higher HDL numbers indicate a better heart health.

HDL Cholesterol Level	HDL-Cholesterol Category
Less than 40mg/dl	Low; major risk factor for heart disease
60 mg/dL or more	Borderline High; Helps lower the risk of heart disease

Triglyceride levels that are borderline high (150-199 mg/dL) or high (200 mg/dL or more) may need treatment for some people. Triglycerides can also raise the risk of heart disease.

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What are the Symptoms and Causes of High Cholesterol?

High blood cholesterol itself does not cause any symptoms, so people are unaware of the fact that their cholesterol level is too high. A blood test is the only way to detect high cholesterol levels.

Many different factors can lead to high blood cholesterol levels like lifestyle factors and underlying health conditions

Poor, Unhealthy Diet: Eating foods rich in saturated fats can elevate the cholesterol levels. Cholesterol-rich foods such as red meat, full dairy products can also up the total cholesterol.

Being Obese: A body mass index of 30 can put one at risk of high cholesterol. Waist circumference size has a direct link with cholesterol level. A waist circumference of at least 40 inches (102 centimeters) for men and waist circumference of at least 35 inches (89 centimeters) for women can raise cholesterol level.

Smoking and Alcohol: Acrolein a chemical found in cigarettes stops HDL (good cholesterol) transporting cholesterol from fatty deposits to the liver, leading to atherosclerosis (narrowing of the arteries). Regular alcohol consumption can increase the levels of triglycerides.

Lack of Exercise may elevate LDL cholesterol and put you at risk of heart disease. Regular exercise will help increase HDL (good) cholesterol and lower the LDL.

Genetic Factors: High cholesterol can run in families and is caused by gene alteration. This condition is known as familial hypercholesterolemia. People with familial hypercholesterolemia have elevated cholesterol from birth which can lead to heart problems at an early age. If there is a family history of High cholesterol all family members including children should be screened.

Health Conditions: Hypertension, diabetes, kidney disease, liver disease and hypothyroidism can also cause raised levels of cholesterol

Age and Sex: Males are more likely to have heart attack than females; older the age greater is the likelihood of atherosclerosis.

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What are the Complications of High Cholesterol?

High cholesterol can cause atherosclerosis, a dangerous accumulation of cholesterol and other deposits on the walls of the arteries. These deposits (plaques) can reduce blood flow through the arteries, which can cause complications, such as chest pain, heart attack and stroke.

How do you Diagnose High Cholesterol?

Physical examination and laboratory tests are done to identify secondary causes of hyperlipidemia or familial disorders, if lipoprotein levels are high.

Lipoprotein profile blood test can help determine the amount of total cholesterol, HDL (good) cholesterol, LDL (bad) cholesterol and triglycerides. The blood test is carried out after 12 hours of fasting. The laboratory professional will take a blood sample either using a needle and a syringe or by pricking your finger.

"Atherogenic" Cholesterol or Non-High-Density Lipoprotein (non-HDL) Test

A new type of test known as non-high-density lipoprotein (non-HDL) test is used in some cases because of the following reasons –

• The test is considered to be more accurate in estimating cardiovascular (CVD) disease risk
• No requirement of fasting prior to the test
• More convenient when compared to lipid profile test

Non-HDL-cholesterol (non-HDL-C) is calculated by subtracting HDL-C (good cholesterol) result from the total cholesterol result. It represents the "atherogenic" cholesterol — the cholesterol that can build up in the arteries, form plaques and blockages.

How do you Treat High Cholesterol?

The main goal of cholesterol-lowering treatment is to lower LDL (bad) cholesterol level enough to reduce the risk of developing atherosclerotic heart disease and heart attack (myocardial infarction).

There are two main ways to lower your cholesterol:

Therapeutic Lifestyle Changes (TLC)

Diet modification is the initial phase of treatment and is tried for several months before drug therapy is added. Diet modifications include reducing total fat intake to 30% of the total calories consumed. Dietary counseling is often recommended to assist people with these adjustments to their eating habits.

Try to cut down or avoid the following foods which are rich in saturated fats:

• Fatty cuts of meat and meat products, such as sausages and pies
• Butter, lard and ghee
• Dairy products, particularly cheese
• Chocolates, cakes, cookies
• Coconut and palm oil

Consumption of foods rich in omega 3 fatty acids is thought to be beneficial for people with high triglyceride level.

Exercise and weight management may also aid in lowering cholesterol levels.

Drug Treatment: Cholesterol lowering drugs are used together with Lifestyle Changes to lower the levels of LDL. Different types of cholesterol-lowering drugs work in different ways. The most commonly used cholesterol-lowering medications are:

Statins: Block the enzyme present in the liver that helps to make cholesterol. The blockage results in the reduction of blood cholesterol level. Patients are initially started on atorvastatin, other statins include simvastatin, rosuvastatin.

Some people can experience certain side effects using statins which include headache, muscle pain, indigestion, diarrhea, constipation.

Bile acid binding resins: Cholestyramine (Prevalite), colesevelam (Welchol) and colestipol (Colestid).

Medications lower cholesterol level by binding to the bile acids (the substance needed for digestion). Hence, liver uses more cholesterol to make more bile acids which lower the cholesterol levels in the blood.

Cholesterol absorption inhibitors: The drug ezetimibe blocks the absorption of cholesterol from food and bile juices in the intestines into the blood. Ezetimibe can be taken in combination with statins. Ezetimibe taken on its own rarely causes side effects.

Injectable drugs: In people who have an intolerance to statins or other cholesterol-lowering drugs and have very high levels of LDL cholesterol - alirocumab and evolocumab can be prescribed.

Cholesterol Treatment in Children

In those who are 2 years old or above who suffer from high cholesterol level and obesity both diet and exercise are found to be effective.

In children age 10 and older if they have extremely high cholesterol levels - cholesterol-lowering drugs such as statins can be prescribed.

How Do you Prevent High Cholesterol?

Cholesterol levels can be lowered and managed in the following ways:

• Eating healthy, balanced diet that is low in saturated fat such as oily fish, avocado, nuts and seeds, sunflower and olive oil. Include plenty of fruits and vegetables
• Quit smoking and abstain from alcohol
• Exercise regularly