Cholesterol and Lipid Management
Cholesterol is a substance that is in the body and carried in the blood. It forms the building blocks of other compounds needed for your body to function. Cholesterol in the body is from two sources; food that we ingest and production in the liver. Foods from animal sources such as meat, poultry, and full fat dairy products contain cholesterol. More cholesterol is made in the liver when our diets are high in saturated and trans fats.
There are two types of cholesterol in the body: LDL – low density lipoprotein (“bad” cholesterol) and HDL – high density lipoprotein (“good” cholesterol). LDL carries cholesterol to all parts of the body, but too much LDL can lead to deposition in the walls of arteries. The LDL cholesterol binds with fats and other substances to form plaque in the walls of arteries. In contrast, HDL cholesterol carries harmful cholesterol out of the arteries and helps to prevent plaques formation.
Why it is Important to Pay Attention to Lipid Levels; 30% of women have elevated levels
98.9 million Americans age 20 and older have total blood cholesterol levels of 200 milligrams per deciliter (mg/dL) or higher: 45.3 million men and 53.6 million women; 30% of women will have an LDL cholesterol greater than 130 mg/dL.
Cholesterol generated plaque leads to narrowed arteries and blood flow is reduced. This plaque can result in heart disease (reduced blood flow to the arteries of the heart – the coronary arteries) and strokes (reduced blood flow to the brain). Plaque can also break off and cause a heart attack or stroke. Cholesterol levels are checked in order to intervene when LDL levels are high, and thus lower ones risk of cardiac disease and stroke.
MANAGEMENT OF ABNORMAL VALUES
Target levels for cholesterol There is no one target total cholesterol or LDL level. Interventions are generally recommended based on: age, blood pressure, total cholesterol, LDL cholesterol, family history of cardiac disease. Other extremely important groups include those with established cardiovascular disease and diabetes. Other factors which can be used to stratify for treatment include those who have an elevated coronary artery calcium score, and elevated c- reactive protein and
Who needs to be treated for elevated cholesterol ? There is no longer a one size fits all “target” LDL goal. Recently there have been identified four major primary- and secondary-prevention patient groups who should be treated.
The four treatment groups include:
Individuals without evidence of cardiovascular disease or diabetes but who have LDL-cholesterol levels between 70 and 189 mg/dL and a 10-year risk of atherosclerotic cardiovascular disease >7.5%. The Framingham Risk Calculator http://cvdrisk.nhlbi.nih.gov is generally recommended to be used to calculate this risk. For Individuals with a 10-year risk of cardiovascular disease of less than 7.5%, a lifetime risk calculator can be used, Q-RISK https://qrisk.org/lifetime/index.php. This calculator is also useful to assess how altering variables such as cholesterol, will impact on risk of cardiovascular disease.
Individuals with LDL-cholesterol levels >190 mg/dL, such as those with familial hypercholesterolemia. High intensity statin therapy should be considered.
Individuals with clinical atherosclerotic cardiovascular disease.
Individuals with diabetes aged 40 to 75 years old with LDL-cholesterol levels between 70 and 189 mg/dL and without evidence of atherosclerotic cardiovascular disease.
Pharmaceutical approaches to lower cholesterol
Generally, the decision to start pharmaceutical methods to lower cholesterol is made on an individualized basis. The main approach to lower cholesterol through pharmaceutical methods is through the use of a drug class called statins. These drugs disrupt production of cholesterol by blocking an enzyme inside the liver cells, resulting in less cholesterol being released into the bloodstream. These drugs may also reduce the inflammatory process that is set up in plaque. Other drug types may also be employed. Statins may be categorized as low, high or medium intensity.
Statins may generally be recommended for primary prevention of atherosclerotic cardiovascular disease for primary prevention in individuals with an LDL greater than 190 mg/dL, those with ages 40-75 with diabetes and LDL levels between 70 to 189 mg/dL; primary prevention in individuals ages 40-75 with an LDL of 70 to 189 and an estimated atherosclerotic cardiovascular disease risk (ASCVD) of > 7.5%. Additional factors may be considered when the risk decision is uncertain and these include: LDL > 160mg/dL, family history of premature ASCVD (mother ,father or sibling with premature ASCVD - women less than the age of 65 years and men less than 55 years), hs-CRP > 2.0, coronary artery calcium score (CAC) > 300 Agaston units or greater than 75th percentile for age sex and ethnicity, ankle –brachial index (ABI) <0.9.
General guidelines are detailed below:
Women with cardiovascular disease: several large trials have demonstrated that aggressive lipid lowering is beneficial in people with coronary heart disease. Many healthcare providers recommend treating all patients with CVD with high-dose statin therapy. Lifestyle interventions will also be reviewed. A target LDL cholesterol level below 70 to 80 mg/dL is recommended for people who have CVD and have multiple major risk factors (such as diabetes or smoking). A target LDL cholesterol level less than 100 mg/dL is recommended for people who have CVD but do not have many additional risk factors. Lifestyle changes as well as nonstatin medications may be recommended when LDL cholesterol levels are higher than 100 mg/dL (2.59 mmol/L).
High triglycerides: elevated triglycerides have not generally been thought to pose the same risk of disease as elevated LDL cholesterol. However, healthcare providers often recommend treatment for people with elevated triglyceride levels if they have very high levels (>500 to 1000 mg/DL); also have high LDL cholesterol or low HDL cholesterol levels; have a strong family history of CHD; have other risk factors for CHD.
Diabetes: people with diabetes (type 1 or 2) are at high risk of heart disease. Thus, an LDL level below 100 mg/dL (2.59 mmol/L) is recommended in many people with diabetes.
MOST WOMEN WITH ELEVATED CHOLESTEROL
Most women will fall into the group of LDL between 70-189 mg/dL. In order to begin to explore the use of a statin the ASCVD risk should be calculated.
- If it is > or equal to 7.5%; a moderate or high intensity statin can be reviewed.
- If it falls between 5% - 7.5% a moderate intensity statin can be considered.
- Other factors should also be considered: family history, hs-CRP, CAC, ABI.
The anticipated therapeutic response is:
- Reduction of LDL greater than 50% for high intensity statin.
- Reduction of LDL 30-50% for moderate intensity statin.
The Framingham Risk Calculator http://cvdrisk.nhlbi.nih.gov is generally recommended to be used to calculate this risk.
For Individuals with a 10-year risk of cardiovascular disease of less than 7.5%, a lifetime risk calculator can be used ,Q-RISK https://qrisk.org/lifetime/index.php.
Additional risk stratification
- Family history of premature ASCVD; mother, father or sibling with premature ASCVD - women less than the age of 65 years and men less than 55 years
- hs-CRP > 2.0
- coronary artery calcium score (CAC) > 300 Agaston units or greater than 75th percentile for age sex and ethnicity
- ankle –brachial index (ABI) <0.9
NATURUAL METHODS TO LOWER CHOLESTEROL
A hear healthy lifestyle should always be recommended. This includes regular aerobic activity, smoking cessation and maintain a healthy weight. High blood pressure and diabetes should also be controlled.
1. Aerobic exercise daily, a minimum of 30 minutes an optimally 60 to 90 minutes, alternating moderate-intensity days with vigorous intensity days
2. Full-body resistance routine two to three times weekly
3. Stretching exercises daily to greatly enhance your overall flexibility and ability to exercise more freely.
Loose excess weight, especially weight around the middle
A Mediterranean Diet appears to reduce the risk of cardiovascular events and improve cholesterol levels. The Mediterranean Diet is rich in fruits, vegetables, whole grains, beans, nuts, and seeds and include olive oil as an important source of fat; there are typically low to moderate amounts of fish, poultry, and dairy products, and there is little red meat. Multiple studies support the Mediterranean Diet eating lifestyle for the prevention of cardiac disease, and improved cholesterol levels. A good resource for Mediterranean Diet is http://www.mayoclinic.org/healthy-lifestyle/nutrition-and-healthy-eating/in-depth/mediterranean-diet/art-20047801?pg=1
The DASH Diet is also recommended. The DASH diet is a plant-focused diet, rich in fruits and vegetables, nuts, with low-fat and non-fat dairy, lean meats, fish, and poultry, mostly whole grains, and heart healthy fats. Salt is also limited. Resource: http://dashdiet.org/default.asp.
- Consume a diet rich in fruits, vegetables, whole grains.
- Limit intake of sweets, sugars and red meats.
- 5-6% of calories from saturated fat.
- Reduce percent of saturated fat.
- Reduce percent of calories from trans fats.
- Consume no more than 2,400 mg of sodium each day.
1. FISH OIL AND OMEGA-3 FATTY ACIDS: Populations with high intakes of omega-3 polyunsaturated fatty acids (such as the Inuit) have low rates of heart disease; this observation has increased interest in the possible benefit of fish oils. Rich sources of omega-3 fatty acids come from fatty fish, especially salmon, and plant sources such as flaxseed and flaxseed oil, canola oil, soybean oil, and nuts.
2. Flaxseed: Interventions using flaxseed appear to reduce LDL, but these may be limited to flaxseed and flaxseed lignans; flaxseed oil does not clearly lower LDL. Flaxseed and flaxseed derivatives do not seem to reduce triglyceride levels.
3. SOY: An excellent source of protein, also contains isoflavones, which are phytoestrogens. Isoflavones are micronutrient substances that, in nonhuman primates, have properties similar to estrogen, including an effect on cholesterol levels. It has been suggested that the lower risk of heart disease among Asian compared to Western populations is due to the high consumption of soybean products. It is possible that intake of soy proteins has other vascular benefits.
4. RED YEAST RICE: Red yeast rice is a fermented rice product that has been used in Chinese cuisine and medicinally to promote "blood circulation". The product contains varying amounts of a family of naturally occurring substances called monacolins that have HMG CoA reductase inhibitor activity. Other active ingredients in red yeast rice that may affect cholesterol lowering include sterols (beta-sitosterol, campesterol, stigmasterol, sapogenin), isoflavones, and monounsaturated fatty acids. Treatment with red yeast rice 1800 mg twice daily may result in significant reductions in LDL. Not all strains of red yeast rice are alike and results of these clinical trials may not generalize to different preparations. There is substantial variability across commercial preparations.
5. POLYPHENOLS: Polyphenols are substances found primarily in plants, and foods made from plants such as tea, coffee, cocoa, olive oil, and red wine, that appear to have antioxidant effects. They also appear to have immunomodulatory and vasodilatory properties that could contribute to cardiovascular risk reduction. Polyphenols include flavonoids and flavonoid derivatives, lignans, phenolic acids, and stilbenes. Resveratrol, a polyphenol (a stilbene) that occurs naturally in several plants, in particular in the skin of red grapes, has been ascribed a number of health benefits, especially against atherosclerosis.
6. NUTS: Small randomized trials have shown that walnuts, which are rich in polyunsaturated fatty acids, have a beneficial effect on serum lipids. Other trials demonstrated similar lipid lowering effects with almonds and pistachios and other nuts. In a review from the prospective Adventist Health Study, individuals who consumed nuts more than four times per week had significant reductions in mortality from coronary heart disease compared to those who consumed nuts less than once per week.
7. TEA: A 2013 meta-analysis of seven randomized trials found that consumption of tea reduced LDL. There was moderate heterogeneity across the trials.
8. FIBER: Certain soluble fibers (psyllium, pectin, wheat dextrin, and oat products) will reduce LDL. In a meta-analysis, every gram increase in soluble fiber reduced LDL-C by an average of 2.2 mg/dL, this effect was similar with various soluble fibers. A meta-analysis of randomized trials found that whole grain diets reduce LDL and total cholesterol, and that whole grain oats were particularly effective. The addition of psyllium supplementation may result in small further reductions in LDL. Therapy that combines soluble fiber with plant sterols may also be of benefit. In a randomized crossover trial in adults with initial LDL concentrations between 100 and 160 mg/dL, four weeks of therapy with cookies that provided 2.6 g/day of plant sterols and 10 g/day psyllium (7.7 g/day soluble fiber) decreased LDL levels by 10 percent. Studies have shown that 9 to 10 grams daily of psyllium, the equivalent of about 3 teaspoons daily of Metamucil, reduced LDL levels.
9. PLANT STEROLS: Plant sterols are similar in chemical structure to cholesterol, differing in their side chain configuration. The mechanism by which they lower cholesterol is thought to involve inhibition of cholesterol absorption. Ingestion of naturally occurring plant sterols may be associated with a reduced risk of cardiovascular events. These should be addressed with some caution however. A study of dietary supplementation with plant sterols in mice found harmful vascular effects including impaired endothelial function and increased atherogenesis. Local accumulation of plant sterols has been observed in patients with aortic valve lesions.
10. CALCIUM: Human and animal studies have suggested that calcium intake may affect the serum lipid concentration by binding to fatty acids and bile acids in the gut, thereby interfering with lipid absorption. In addition, at least two randomized, controlled trials have found that calcium supplementation causes potentially beneficial changes in circulating lipids. The risk of cardiovascular disease with calcium supplementation must also be balanced.
1. Calculate your risk of cardiac disease based on your cholesterol values and other factors with the Framingham and Q-RISK calculators.
2. Set goals for your cholesterol, weight, exercise and overall healthful lifestyle.
3. Review with your health care provider whether pharmacologic approaches are absolutely required, or if a trial of natural approaches to an elevated cholesterol are reasonable.
4. Achieve your optimal weight
5. Exercise for at least 30 minutes each day.
6. Limit intake of foods full of saturated and trans fats and dietary cholesterol.
7. Eat more fiber rich foods.
8. Choose protein rich plant foods – such as beans, nuts and seeds.
9. Consider the following supplements:
a. Red rice yeast – resource https://www.thorne.com/products/dp/choleast-trade
b. Fish oil – resource https://www.thorne.com/products/dp/super-epa
c. Fiber supplements – resource https://www.emersonecologics.com/Products/EmersonMain/PID-N5975.aspx
d. Plant sterols – resource http://www.pureencapsulations.com/lipid-support-formula.html
e. Calcium (500 mg per day)