Dr Praveen Ramachandra
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Patient Education on Lipids

Cholesterol is a waxy substance that is found in the fats (lipids) in blood. While, body needs cholesterol to continue building healthy cells, having high cholesterol can increase the risk of heart disease.

When a body has high cholesterol, it may develop fatty deposits in the blood vessels. Eventually, these deposits make it difficult for enough blood to flow through the arteries. Also, heart may not get as much oxygen-rich blood as it needs, which increases the risk of a heart attack. Decreased blood flow to the brain can cause a stroke.

Fig 1: Difference between the normal artery and the artery in which the cholesterol is deposited


High cholesterol (hypercholesterolemia) can be inherited, but it is often the result of unhealthy lifestyle choices, and thus preventable and treatable. A healthy diet, regular exercise and sometimes medication can go a long way toward reducing high cholesterol.

Symptoms

High cholesterol has no symptoms. A blood test is the only way to detect high cholesterol.

When to see a doctor

Ask the doctor for a baseline cholesterol test at the age of 20 and then retest the cholesterol at least every five years. If the test results are not within desirable ranges, doctor may recommend more frequent measurements. He may also suggest to do more frequent tests if there is a family history of high cholesterol, heart disease or other risk factors, such as smoking, diabetes or high blood pressure.

Causes

Cholesterol is carried through blood, attached to proteins. This combination of proteins and cholesterol is called a lipoprotein. There are different types of cholesterol, based on what type of cholesterol the lipoprotein carries. They are:

·        Low-density lipoprotein (LDL): LDL or "bad" cholesterol transports cholesterol particles throughout body. LDL cholesterol builds up in the walls of arteries, making them hard and narrow.

·        Very-low-density lipoprotein (VLDL): This type of lipoprotein contains the most triglycerides, a type of fat, attached to the proteins in blood. VLDL cholesterol makes LDL cholesterol larger in size, causing blood vessels to narrow. If a person is taking cholesterol-lowering medication but have a high VLDL level, he may need additional medication to lower his triglycerides.

                   

Fig 2: Types of lipoproteins

·        High-density lipoprotein (HDL): HDL or "good" cholesterol picks up excess cholesterol and takes it back to liver.

Factors within your control i.e. inactivity, obesity and an unhealthy diet, contribute to high LDL cholesterol and low HDL cholesterol. Factors beyond your control may play a role, too. For example, your genetic makeup may keep cells from removing LDL cholesterol from your blood efficiently or cause liver to produce too much cholesterol.

Risk factors

The risk factors for high cholesterol that can lead to heart disease include the following:

·        Smoking: Cigarette smoking damages the walls of blood vessels, making them likely to accumulate fatty deposits. Smoking may also lower the level of HDL, or "good," cholesterol.

·        Obesity: Having a body mass index (BMI) of 30 or greater puts a person at risk of high cholesterol.

·        Large waist circumference: The risk increases if a man with a waist circumference of at least 40 inches (102 centimeters) or a woman with a waist circumference of at least 35 inches (89 centimeters).

Fig.3: Risk factors for high cholesterol

·        Poor diet: Food that is high in cholesterol, such as red meat and full-fat dairy products, will increase total cholesterol. Eating saturated fat, found in animal products, and trans fats, found in some commercially baked cookies and crackers, also can raise cholesterol level.

·        Lack of exercise: Exercise helps to boost body's HDL "good" cholesterol while lower the LDL "bad" cholesterol. Not getting enough exercise can lead to high cholesterol.

·        Diabetes: High blood sugar contributes to higher LDL cholesterol and lower HDL cholesterol. High blood sugar also damages the lining of arteries.

 

Complications

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

·        Chest pain: If the arteries that supply heart with blood (coronary arteries) are affected, there are chances of chest pain (angina) and other symptoms of coronary artery disease.

·        Heart attack: If plaques tear or rupture, a blood clot may form at the plaque-rupture site — blocking the flow of blood or breaking free and plugging an artery downstream. If there is partial blood flow to the heart, there is a risk of getting heart attack.

·        Stroke: Similar to a heart attack, if blood flow to any part of the brain is blocked by a blood clot, a stroke occurs.

 

Tests and diagnosis

A blood test to check cholesterol levels is called as a lipid panel or lipid profile — typically reports:

·        Total cholesterol

·        LDL cholesterol

·        HDL cholesterol

·        Triglycerides — a type of fat in the blood

For the most accurate measurements, a person should not eat or drink anything (other than water) for nine to 12 hours before the blood sample is taken.

Interpreting the numbers

Cholesterol levels are measured in milligrams (mg) of cholesterol per deciliter (dL) of blood in the United States and some other countries. Canada and most European countries measure cholesterol in millimoles (mmol) per liter (L) of blood. Consider these general guidelines when you get your cholesterol test results back to see if your cholesterol falls in ideal levels.

Importantly, your doctor may determine that your cholesterol needs treatment based on the presence of heart disease or on your individual risk of heart attack, even if the cholesterol values do not seem particularly elevated.

Total cholesterol
(U.S. and some other countries)

Total cholesterol*
(Canada and most of Europe)

 

Below 200 mg/dL

Below 5.2 mmol/L

Best

200-239 mg/dL

5.2-6.2 mmol/L

Borderline high

240 mg/dL and above

Above 6.2 mmol/L

High

 

LDL cholesterol
(U.S. and some other countries)

LDL cholesterol*
(Canada and most of Europe)

 

Below 70 mg/dL

Below 1.8 mmol/L

Best for people with heart disease

Below 100 mg/dL

Below 2.6 mmol/L

Best for people at risk of heart disease. Below 70 mg/dL (1.8 mmol/L) may be ideal for people who have heart disease.

100-129 mg/dL

2.6-3.3 mmol/L

Near ideal

130-159 mg/dL

3.4-4.1 mmol/L

Borderline high

160-189 mg/dL

4.1-4.9 mmol/L

High

190 mg/dL and above

Above 4.9 mmol/L

Very high

 

HDL cholesterol
(U.S. and some other countries)

HDL cholesterol*
(Canada and most of Europe)

 

Below 40 mg/dL (men)
Below 50 mg/dL (women)

Below 1 mmol/L (men)
Below 1.3 mmol/L (women)

Poor

50-59 mg/dL

1.3-1.5 mmol/L

Better

60 mg/dL and above

Above 1.5 mmol/L

Best

 

Triglycerides
(U.S. and some other countries)

Triglycerides*
(Canada and most of Europe)

 

Below 150 mg/dL

Below 1.7 mmol/L

Best

150-199 mg/dL

1.7-2.2 mmol/L

Borderline high

200-499 mg/dL

2.3-5.6 mmol/L

High

500 mg/dL and above

Above 5.6 mmol/L

Very high

The American Heart Association (AHA) recommends that a triglyceride level of 100 mg/dL (1.3 mmol/L) or lower is considered "optimal." The AHA says this optimal level would improve the heart health. However, the AHA doesn't recommend drug treatment to reach this level. Instead, for those trying to lower their triglycerides to this level, lifestyle changes such as diet, weight loss and physical activity are encouraged. That's because triglycerides usually respond well to dietary and lifestyle changes.

LDL targets differ
Because LDL cholesterol is a major risk factor for heart disease, it's the main focus of cholesterol-lowering treatment. A person’s target LDL number can vary, depending on his underlying risk of heart disease.

Most people should aim for an LDL level below 130 mg/dL (3.4 mmol/L). If a person has other risk factors for heart disease, the target LDL may be below 100 mg/dL (2.6 mmol/L). If he is at very high risk of heart disease, he may need to aim for an LDL level below 70 mg/dL (1.8mmol/L). In general, the lower your LDL cholesterol level is, the better.

A person is considered to be at a high risk of heart disease if he:

·        Has had a previous heart attack or stroke

·        Has artery blockages in his neck (carotid artery disease)

·        Has artery blockages in his arms or legs (peripheral artery disease)

·        Has known diabetes that requires treatment

In addition, two or more of the following risk factors might also place him in the high-risk group:

·        Smoking

·        High blood pressure

·        Low HDL cholesterol

·        Family history of early heart disease

·        Age older than 45 if he is a man, or older than 55 if she is a woman

·        Elevated lipoprotein, which is another type of fat (lipid) in blood

Children and cholesterol testing

Children as young as age 2 can have high cholesterol, but not all children need to be screened for high cholesterol. The American Academy of Pediatrics (AAP) recommends a cholesterol test (fasting lipid panel) for all children between the ages of 9 and 11. The AAP also recommends screening for children as young as 1 year who have a known family history of high cholesterol or premature coronary artery disease. The pediatrician may recommend retesting if the child's first test shows he or she has normal cholesterol levels.

The American Academy of Pediatrics also recommends testing if the child's family history for high cholesterol is unknown, but the child has risk factors for high cholesterol, such as obesity, high blood pressure or diabetes.

Treatments and drugs

Lifestyle changes such as exercising and eating a healthy diet are the first line of defense against high cholesterol. But, if the person has made these important lifestyle changes and his cholesterol levels remains high, his doctor may recommend medication.

The specific choice of medication or combination of medications depends on various factors, including individual risk factors, such as age, person’s current health and possible side effects. Common choices include:

·        Statins:These are among the most commonly prescribed medications for lowering cholesterol which block a substance that liver needs to make cholesterol. This causes liver to remove cholesterol from the blood. Statins may also help the body to reabsorb cholesterol from built-up deposits on artery walls, potentially reversing coronary artery disease.

·        Bile-acid-binding resins: Liver uses cholesterol to make bile acids, a substance needed for digestion. The medications cholestyramine (Prevalite), colesevelam (Welchol) and colestipol (Colestid) lower cholesterol indirectly by binding to bile acids. This prompts liver to use excess cholesterol to make more bile acids, which reduces the level of cholesterol in blood.

·        Cholesterol absorption inhibitors: Small intestine absorbs the cholesterol from diet and releases it into the bloodstream. The drug ezetimibe helps reduce blood cholesterol by limiting the absorption of dietary cholesterol. It can be used in combination with any of the statin drugs.

·        Combination of cholesterol absorption inhibitor and statin: The combination drug ezetimibe-simvastatin decreases both absorption of dietary cholesterol in the small intestine and production of cholesterol in the liver.

·        Injectable medications. A new class of drugs can help the liver to absorb more LDL cholesterol, which lowers the amount of cholesterol circulating in the blood. The Food and Drug Administration recently approved alirocumab (Praluent) and evolocumab (Repatha) for people who have a genetic condition that causes very high levels of LDL. These drugs also may be used for people who have had heart attacks or strokes and need additional lowering of their LDL levels. These injectable drugs are administered at home one or two times a month.

 

Medications for high triglycerides

Medications for high triglycerides include the following:

·        Fibrates. The medications fenofibrate and gemfibrozil decrease triglycerides by reducing the liver's production of very-low-density lipoprotein (VLDL) cholesterol and by speeding up the removal of triglycerides from the blood. VLDL cholesterol contains mostly triglycerides.

·        Niacin. Niacin decreases triglycerides by limiting the liver's ability to produce LDL and VLDL cholesterol. But niacin doesn't provide any additional benefit than using statins alone. Niacin has also been linked to liver damage and stroke, so most doctors now recommend it only for people who can't take statins.

·        Omega-3 fatty acid supplements. Omega-3 fatty acid supplements can help to lower the cholesterol. A person can take it over-the-counter supplements, or a doctor may prescribe Lovaza, a prescription omega-3 fatty acid supplement, as a way to lower the triglycerides. These supplements may be taken with another cholesterol-lowering medication, such as a statin. If a person chooses to take over-the-counter supplements, he should ask the doctor's advice first. If he is taking other medications, Omega-3 fatty acid supplements could affect those medications

Tolerance varies

Tolerance of medications varies from person to person. The common side effects are muscle pains, stomach pain, constipation, nausea and diarrhea. If a person decides to take cholesterol medication, doctor may recommend liver function tests to monitor the medication's effect on his liver.

Children and cholesterol treatment

Diet and exercise are the best initial treatment for children age 2 and older who have high cholesterol or who are obese. The American Academy of Pediatrics also recommends treatment with prescription drugs, such as statins, for children age 8 and older if a child has a high level of LDL cholesterol. However, this recommendation is controversial. The long-term effects of cholesterol-lowering drugs have not been extensively studied in children. In addition, certain cholesterol medications such as niacin are not recommended for children.

Lifestyle and home remedies

Lifestyle changes are essential to improve the cholesterol level. To achieve normal cholesterol, a person should lose excess weight, eat healthy food and increase physical activity and quit smoking.

Lose extra weight

Excess weight contributes to high cholesterol. Losing even 5 to 10 pounds can help lower total cholesterol levels. Start by taking an honest look at your eating habits and daily routine. Consider your challenges to weight loss — and ways to overcome them. Set long-term, sustainable goals.

Eat heart-healthy foods

What you eat has a direct impact on your cholesterol level. In fact, a diet rich in fiber and other cholesterol-lowering foods may help lower cholesterol as much as statin medication for some people.

·        Choose healthier fats: Saturated fat and trans fat raise your total cholesterol and LDL cholesterol. Get no more than 10 percent of your daily calories from saturated fat. Monounsaturated fat — found in olive, peanut and canola oils — is a healthier option. Almonds and walnuts are other sources of healthy fat.

·        Eliminate trans fats: Trans fats, which are often found in margarines and commercially baked cookies, crackers and snack cakes, are particularly bad for cholesterol levels. Not only do trans fats increase total LDL ("bad") cholesterol, but they also lower HDL ("good") cholesterol.

You may have noticed more food labels now market their products as "trans fat-free." But don't rely only on this label. In the United States, if a food contains less than 0.5 grams of trans fat a serving, it can be marked trans fat-free. It may not seem like much, but if you eat a lot of foods with a small amount of trans fat, it can add up quickly. Instead, read the ingredients list. If a food contains partially hydrogenated oil, that's a trans fat, then you should look for an alternative.

·        Limit your dietary cholesterol: Aim for no more than 300 milligrams (mg) of cholesterol a day — or less than 200 mg if a person has heart disease. The most concentrated sources of cholesterol include organ meats, egg yolks and whole milk products. Use lean cuts of meat, egg substitutes and skim milk instead.

·        Select whole grains: Various nutrients found in whole grains promote heart health. Choose whole-grain breads, whole-wheat pasta, whole-wheat flour and brown rice. Oatmeal and oat bran are other good choices.

·        Stock up on fruits and vegetables: Fruits and vegetables are rich in dietary fiber, which can help lower cholesterol. Snack on seasonal fruits. Experiment with vegetable-based casseroles, soups and stir-fries.

Fig 4: An example for cholesterol diet menu

·        Eat heart-healthy fish: Some types of fish — such as cod, tuna and halibut — have less total fat, saturated fat and cholesterol than do meat and poultry. Salmon, mackerel and herring are rich in omega-3 fatty acids, which help to promote heart health.

·        Drink alcohol only in moderation: Moderate use of alcohol may increase the levels of HDL cholesterol — but the benefits are not strong enough to recommend alcohol for anyone who doesn't drink already. If you choose to drink, do so in moderation. This means no more than one drink a day for women, and one to two drinks a day for men.

Exercise regularly

Regular exercise can help improve the cholesterol levels. With your doctor's OK, work up to 30 to 60 minutes of exercise a day. Take a brisk daily walk. Ride a bike. Swim laps. Find an exercise buddy or join an exercise group. And, you don't need to get all 30 to 60 minutes in one exercise session. If you can squeeze in three to six 10-minute intervals of exercise, you'll still get some cholesterol-lowering benefits.

Don't smoke

If you smoke, stop. Quitting can improve your HDL cholesterol level. And the benefits don't end there. Just 20 minutes after quitting, your blood pressure decreases. Within 24 hours, your risk of a heart attack decreases. Within one year, your risk of heart disease is half that of a smoker's. Within 15 years, your risk of heart disease is similar to that of someone who's never smoked.

If you choose to take cholesterol-lowering supplements, remember the importance of a healthy lifestyle. If your doctor prescribes medication to reduce your cholesterol, take it as directed. Make sure your doctor knows which supplements you're taking as well.

Prevention

The same heart-healthy lifestyle changes that can lower the cholesterol, and helps to prevent from having high cholesterol in the first place. To help prevent high cholesterol, one can:

·        Lose extra pounds and maintain a healthy weight

·        Quit smoking

·        Eat a low-fat, low-salt diet that includes many fruits, vegetables and whole grains

·        Exercise on most days of the week for at least 30 minutes

·        Drink alcohol in moderation, if at all.