Introduction to what is cholesterol

Cholesterol is a soft and waxy kind of lipid (or fat) found in the body. It is produced naturally by the liver and is required by every cell of the body. It is required to secrete certain hormones, to create cell membranes and to form Vitamin D in the body. The cholesterol so produced by the liver is transported to every cell of the body through the blood. Cholesterol does not naturally dissolve in water or blood, so it is transported through the blood using a kind of protein called lipoprotein produced by the body. Think of the lipoprotein as a car that is used to transport cholesterol which is riding on it.

Cholesterol can also be absorbed from the foods we consume. Foods that are rich in saturated fats, transfats and animal fats are high in cholesterol, so a diet high in such foods can spike the cholesterol levels in the body.

At this juncture, it is important to note that there are 3 kinds of fats or lipids in the body:

• Low Density Lipoprotein (LDL) Cholesterol (LDL-C): Also called bad cholesterol, this is a thin and watery kind of fat that moves easily through the body. They deposit in arteries and cause atherosclerosis. Hydrogenated oils, vanaspati, butter, cream, cheese and certain vegetable oils are high in this, which is what makes cooking using them an unhealthy alternative. Its important to have less of LDL cholesterol in the body for good health.
• High Density Lipoprotein (HDL) Cholesterol (HDL-C): Also called good cholesterol, this is the type of cholesterol that performs the functions mentioned above. They are thick or dense and move steadily through the blood. They act as a tow-truck and pull the bad cholesterol up to the liver which then processes or breaks them down. Ghee, almonds, peanuts, low-fat dairy and certain vegetable oils are all rich in this, so consuming them, or cooking using them is a healthy alternative. It is important to have more of HDL cholesterol in the body for good health.
• Triglycerides (TG): This fat is slightly different from cholesterol. They are created by the body naturally. They act as fuel or source of energy for various body functions. For ex, the functions performed by cholesterol mentioned above, also use triglycerides as energy. When we consume more food or calories than what is required by the body to produce energy needed for the work that we do, some of this excess food (irrespective of whether its carbohydrates, proteins or fats) is converted into triglycerides and stored in the fat cells.

When we say exercise burns fat or calories, what is happening is that the excess triglycerides are consumed as fuel and in the process broken down by the body. So also, the HDL cholesterol becomes more active and efficient in pulling the LDL cholesterol to the liver for breaking down. That is why exercise is good while a sedentary lifestyle is risky, for anybody.

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What is Hypercholesterolemia?

Hyperlipidemia is an umbrella name for a condition in which there is excess of fat in the body which is not good for the person. It is a set of 2 conditions:

• Hypercholesterolemia: In this, there is excess LDL or bad cholesterol (LDL-C) in the body.
• Hypertrigylceridemia: In this, there is excess of triglycerides in the body.

When the person suffers from only an excess of LDL-C, (s)he is diagnosed with ‘hypercholesterolemia’ and the term hyperlipidemia does not feature in the report.

So how much fat is too much? Hypercholesterolemia is declared by the doctors when:

• The patient is healthy, without any risk factor and has LDL-C levels of 190 mg/dL or more
• The patient has one major risk factor and has LDL-C levels of 160 mg/dL or more
• The patient has two major risk factors and has LDL-C levels of 130 mg/dL or more

The person who is at high risk of a cardiovascular event should have a target LDL-C level in the range 70-116 mg/dL.

Types of Hypercholesterolemia

Familial: Here, the genes responsible for removing LDL-C from the blood have mutated over a couple of generations and the person has inherited them now. This again is of 4 types:

• Familial hypercholesterolemia
• Familial combined hyperlipidemia
• Familial dysbetalipoproteinemia
• Familial hypertriglyceridemia

Acquired: This develops when the person has been consuming a diet rich in sugar, saturated fats and transfats over a long time. Such sources of food include red-meat, high-fat dairy, palm and coconut oils, fast foods, fried foods and hydrogenated vegetable oils.

Causes and Risk Factors

Other than the causes mentioned above, risk factors include:

• Age: Being older than 40 years
• Gender: Older men and post-menopausal women are at higher risk than pre-menopausal women.
• High blood pressure
• Chronic Kidney disease
• Polycystic ovary syndrome
• Family history of premature atherosclerotic heart disease
• Diabetes
• Low levels of HDL-C (“good cholesterol”) due to not consuming enough healthy fats
• Race: Asian Indians, Filipinos and Vietnamese are at higher risk than others.
• Sedentary lifestyle with little to no exercise
• Obesity
• Pregnancy and other conditions that increase levels of female hormones
• Underactive thyroid gland (hypothyroidism)
• Medication: Medicines such as beta-blockers, certain birth control pills, some medicines used to treat depression, diuretics (water pills) and medicines used to treat Acne, Organ transplants, Cancer, High blood pressure, Irregular heart rhythms and HIV/AIDS can also raise cholesterol levels.
• Smoking, as this reduces HDL-C levels in the body
• Obstructive liver disease
• Anorexia nervosa
• Nephrotic syndrome
• HIV/AIDS
• Lupus
• Alcohol abuse: excessive drinking can increase the total cholesterol level (LDL-C+HDL-C+TG)
• Stress (mental/emotional)
• Pancreas disease
• Multiple myeloma
• Polycystic ovary syndrome (PCOS)
• Primary biliary cholangitis
• Sleep apnoea

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Signs and Symptoms

• Angina or chest pain
• Xanthomas which are waxy, fatty plaques on the skin (which is basically a build-up of fat under the skin)
• Corneal arcus which is basically cholesterol rings around the iris of the eye
• Cholesterol-containing patches on the eyelids called xanthelasmas

Complications from Hypercholesterolemia

The primary outcome of Hypercholesterolemia is atherosclerosis which is a hardening of blood-vessel walls and narrowing of blood-vessels, due to plaque formation on the blood-vessels walls (happens when LDL-C starts depositing on these walls). Atherosclerosis in turn can cause one or more of these:

• Heart-attack
• Brain Stroke
• Coronary artery disease
• Peripheral artery disease
• Carotid artery disease
• Sudden cardiac arrest
• Microvascular disease
• Hypertension
• Chronic Kidney Disease (both risk-factor and complication)

Diagnosis

• Investigation into personal and family medical-history
• Physical examination for visible signs mentioned earlier
• Lipid Panel blood test which measures total cholesterol, LDL-C, HDL-C and TG levels in the blood. This is usually done after a period of fasting.
• Genetic testing for familial hypercholesterolemia
• Calculating the 10-year Atherosclerotic Cardiovascular Disease (ASCVD) Risk Score

Treatment

• Exercising more and maintaining a healthy weight
• Eating foods low in saturated fat, such as low-fat dairy, healthy fats, fresh fruits and vegetables, whole-grains and lean meat
• Lowering stress levels through yoga, meditation and Tai-chi
• Taking cholesterol-lowering medications (Statins, Bempedoic acid, PCSK9 inhibitors, Niacin, Bile acid sequestrants and Ezetimibe)
• Avoiding tobacco products
• Minimizing alcohol consumption
• Controlling high BP and high blood-sugar
• Lipoprotein apheresis: In this procedure, a device is used to extract blood out of the body, take lipoproteins out of it and then putting blood back into the body. However, this is only in severe cases.

Prevention

The points mentioned above under diet, exercise, stress, tobacco and alcohol, also help in preventing the onset of hypercholesterolemia in people who do not have the condition presently.

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