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Cholesterol, hypercholesterolaemia
Cardiovascular system
Cholesterol is a fatty substance or lipid that plays a vital role in a healthy body. It is an important part of the walls of cells that make up the body's tissues and it is used to produce the body's hormones such as oestrogen, testosterone and corticosteroids. With the exception of eggs, liver and kidneys very little cholesterol is found in foods. Most cholesterol is produced by the body in the liver from saturated fats found in foods, for example from animal fat and certain vegetable oils.

Although cholesterol is important for health, it is recognised that too high a level of cholesterol in the blood increases the risk of coronary heart disease, heart attacks and stroke. In the UK, the average total cholesterol level is 5.5mmol/l. However, as the UK has a much higher incidence of heart disease and stroke than many other countries, this average figure is regarded as too high. Health experts recommend a total cholesterol level less than 5mmol/l. People whose cholesterol level is 5-6.4mmol/l have mildly elevated cholesterol levels, those at 6.5-7.8mmol/l have moderately elevated levels, and those above 7.8mmol/l have very highly elevated levels. The higher the level the greater the risk of developing heart attacks and strokes.

Cholesterol itself is carried in the blood stream by special molecules called lipoproteins. The two main types of lipoproteins are:

Low density lipoproteins (LDL) - carries cholesterol from the liver to the cells. LDL-cholesterol or LDL-C is often known as 'bad cholesterol' as it can cause narrowing of the arteries if there is too much cholesterol than can be used by the cells.

High density lipoprotein (HDL) - carries cholesterol away from the cells and back to the liver, where it is taken out of the circulation by LDL receptors and broken down or removed from the body. HDL-cholesterol or HDL-C is often known as 'good cholesterol' as it may reduce narrowing of the arteries.

When measuring cholesterol levels, it is important not just to measure the total amount of cholesterol (total cholesterol TC), but also to measure the levels of bad cholesterol (LDL-C) and good cholesterol (HDL-C). It is the ratio between good and bad cholesterol (either TC : HDL-C ratio or LDL-C : HDL-C ratio) that determines the risk of cardiovascular disease. For example, it is possible for someone to have a high total cholesterol level but because they also have a high HDL-C level they are at a relatively low risk of developing heart problems. While anyone with a previous history of heart problems such as angina or heart attack should aim to get their total cholesterol below 4mmol/l or their LDL-C below 2mmol/litre.
The most common causes of high cholesterol levels in the blood are too much saturated fat or trans-fats (partially hydrogenated vegetable oils) in the diet, being overweight and a lack of physical exercise. Too much saturated fat or trans-fats leads to an increased production of cholesterol by the liver, increasing both total cholesterol and LDL-C. Saturated fats are found in meat, in meat products such as burgers, sausages and pies, in hard cheese, butter, lard, coconut oil and palm oil. Trans-fats are less obvious as these fats are often used in the manufacture of processed foods, pastries, cakes, biscuits and fast-foods.

Lack of exercise and being overweight leads to an increase in LDL-C and a decrease in HDL-C. Some people have high cholesterol levels as a result of an under active thyroid gland, or chronic kidney failure, or alcohol abuse.

About 1 in 500 people have high cholesterol levels because of an inherited disorder called familial hypercholesterolaemia. These people lack the LDL receptors that are needed by the liver to remove cholesterol from the circulation.

Elevated cholesterol is not a disease in itself, but it does increase the risk of developing other serious diseases such as coronary heart disease and strokes. Excess cholesterol becomes deposited in the walls of the arteries in lumps called plaques. These plaques narrow the arteries, obstruct the flow of blood and increase the chances of a blood clot or thrombosis developing. The circulation of blood to important organs such as the heart and brain is restricted as the arteries first narrow. Subsequently circulation may be stopped altogether if a blood clot should block the artery. If this happens in the blood vessels supplying the heart (the coronary blood vessels), the person may first suffer from angina (chest pain) then later have a heart attack. If the circulation is restricted to the brain, the person may first suffer mild strokes or TIAs (transient ischaemic attacks) or a major stroke that can result in paralysis.
For anyone looking to achieve good cholesterol levels, some simple lifestyle changes are important. Beneficial changes include reducing the amount of saturated fats and trans-fats in the diet, eating 5 portions of fruit and vegetables each day, limiting alcohol consumption, stopping smoking and taking regular exercise (see living with high cholesterol levels in the section below).

If, after a few months of these lifestyle changes, cholesterol levels have not fallen, a cholesterol-regulating drug treatment may be prescribed by a doctor.

There are a number of cholesterol-regulating drugs available including the statins (atorvastatin, fluvastatin, pravastatin, rosuvastatin, and simvastatin) and fibrates (bezafibrate, ciprofibrate, fenofibrate and gemfibrozil) that block the production of cholesterol in the body.

Cholesterol absorption inhibitors (ezetimibe) block the absorption of cholesterol from food as it is digested. Bile acid sequestrants (colestyramine, colestipol and colesevelam) increase the conversion of cholesterol to bile acids in the liver and the bile acids are then eliminated from the body.

If, in addition to raised cholesterol levels, other risks for coronary heart disease are also present, the more likely it is that a combination of these cholesterol-regulating drugs will be used.
When to consult your pharmacist
Many, but not all pharmacists now provide a cholesterol measuring service and it is recommended that all people over the age of 20 should have their cholesterol measured. In addition to measuring cholesterol levels your pharmacist will be able to assess your other risk factors for developing heart attacks and strokes and will be able to advise you on making some healthy lifestyle changes.

If the pharmacist thinks that you are moderately at risk of developing coronary heart disease, he or she may under certain cases, for example men over the age of 55, men aged 45 to 54 and women over the age of 55 who have a close family member who has had coronary heart disease, are smokers, overweight or are of South Asian origin, recommend that you purchase a cholesterol-regulating statin called simvastatin. The medicine must be taken for a long time and must be used as part of a healthy change in lifestyle.

If the pharmacist considers you to be at high risk of developing coronary heart disease, either because of your cholesterol levels or because of the presence of other risk factor, you will be advised to see your doctor.

If you are taking cholesterol-regulating medicines prescribed by your doctor, let your pharmacist know. Some medicines should not be used together or with certain health food supplements. Should you happen to develop muscle pain while taking a statin, tell your pharmacist as it may be a side effect of the medicine.
When to consult your doctor
See your doctor if you suspect that you or a relative have high cholesterol which has not yet been noticed. Your doctor will take a blood sample to measure cholesterol levels, take blood pressure readings and ask questions about lifestyle, personal and family medical history to assess the risk of developing heart disease or stroke and to decide what level of treatment is required.
Living with heart disease
A high cholesterol level is now recognised as one of the main risk factors for coronary heart disease and stroke, the risks increasing the higher the cholesterol level. When other risk factors such as high blood pressure, diabetes, cigarette smoking, high fat diet, lack of exercise and overweight are present, the risks are even greater. Most people with high cholesterol do not experience any obvious symptoms. In fact, the first signs of an underlying problem might be chest pain, heart attack or stroke. That is why it is important to have your cholesterol levels measured and your other risk factors assessed regularly. Improvement in life style can dramatically reduce your chances of getting coronary heart disease, angina, a heart attack or stroke.

If you smoke, you should make every effort to stop the habit. Stopping smoking is the single most significant factor in reducing the risk of coronary heart disease. From the moment you stop smoking, the risk of heart attack starts to reduce. There are many products for nicotine replacement therapy, such as patches, chewing gums, lozenges and nasal sprays, available to purchase over the counter or on prescription that can help reduce the craving to smoke while giving up. Alternatively, there are medicines such as bupropion and varenicline tablets that are available on prescription that help reduce craving and the dependency on nicotine. Whichever products are used, they will only help if you are committed to stop smoking and you will be more likely to succeed if you also receive counselling and support while trying to give up. Do not be afraid to ask your doctor, practice nurse or pharmacist for help.

If you are offered a cigarette, be positive. Tell your family and friends that you have stopped smoking, not that you are trying to give up. Try to occupy your hands and your thoughts in situations when you used to smoke, for example after a meal or with a drink, to break the association of smoking with these social occasions. If you do lapse and smoke a cigarette, do not regard this as having failed to give up. Instead, regard it has a temporary set-back and use it to strengthen your resolve not to have another.

Control your weight. By keeping close to the recommended weight for your height, you can help keep your blood pressure down and reduce the amount of work your heart has to do.

Eat healthily. Three meals - breakfast, lunch and dinner - spread evenly throughout the day is best. Do not skip breakfast as it increases the tendency to snack. Limit the size of your meal portions and do not eat large meals late at night. Choose foods with a low glycaemic index (GI) such as lentils or porridge that are slowly digested and absorbed, so helping keep hunger pangs at bay.

A diet that is low in fat, particularly saturated fat and trans-fats is essential to help lower your blood cholesterol level. So cut down on animal fat, cakes and biscuits. Include a small amount of unsaturated fats such as oily fish (herring, mackerel, salmon), avocados, nuts and olive oil into the diet. Eat a variety of fruit and vegetables. Aim for at least five portions a day. It may sound a lot, but can easily be achieved if you eat an apple, banana or raw carrot as a snack instead of a bag of crisps or biscuits. Salt can contribute to high blood pressure so it is best to limit your intake to no more than 6 grams a day. Stop adding salt to vegetables when cooking and do not automatically sprinkle salt over your food before tasting. You'll not be able to notice the difference after a very short time. Get into the habit of reading the labels on food products and choose those with a low salt and low fat content.

Reduce your alcohol consumption. Although a glass of red wine each day may increase HDL-C levels, heavy alcohol drinking can contribute to high blood pressure, strokes and can damage the heart muscle. Men should not drink more than 4 units of alcohol in any one day, or more than 21 units of alcohol per week. Women should not drink more than 3 units of alcohol in any one day, or more than 14 units of alcohol per week. As a guide, a pint of beer is about 2 units and a small glass of wine is about one and a half units.

Exercise regularly. Physical activity increases levels of HDL-C, decreases total cholesterol and LDL-C levels and halves the risk of developing heart disease. If you've got angina or had a heart attack it is a good idea to speak to your doctor before starting an exercise programme. Take it easy at first and build up your level of fitness gradually. Aim for at least 30 minutes of moderate activity five days a week.
Advice for carers and other family members
Support the person you care for or the person you live with who has high cholesterol levels. Change your eating habits as a family. If you also eat healthily, shopping, cooking and meal times will be easier and there will be less temptation to everyone to eat the wrong things. As heart disease tends to run in families, you will also be reducing your family's risk of angina and heart attacks in the future.

All members of the family should be discouraged from smoking as this helps reducing cravings in the person who has stopped smoking and stops passive smoking which also poses a risk of heart disease.
Useful Tips
  • Eat at least 5 portions of fruit a day (see healthy eating section)
  • Smokers can halve their risk of a heart attack within five years of quitting (see give up smoking section)
  • Physical activity can halve the risk of a heart attack
  • Drink at least 6 to 8 glasses of fluid each day. Water, juice, soya drinks and low-fat milk can also count
  • Grill, steam, microwave, poach, stir fry or oven bake, wherever possible (see healthier eating section)
  • Check food labels for amounts of fat and salt, and reduce your intake
  • Keep alcohol to sensible limits of no more than 2-3 units per day for women or 3-4 units per day for men
  • Aim to keep a healthy weight for your height
Further information
For further advice about lowering your cholesterol contact HEART UK, a registered charity that raises awareness about the risks of high cholesterol, lobbies for better detection of those at risk, funds research into improved treatment and supports health professional training. HEART UK provides information, advice and support to help prevent premature deaths caused by high cholesterol levels and cardiovascular disease.

7 North Road

Helpline: 0845 450 5988 (Tuesday and Thursday from 1000 to 1600)
Health/Helpline enquiries:

For further information on heart disease contact the British Heart Foundation, a registered charity whose mission is to play a leading role in the fight against disease of the heart and circulation through pioneering research, vital prevention activity and ensuring quality care and support for everyone living with heart disease.

British Heart Foundation
Heart helpline: 0300 330 3311

Reviewed on 25 October 2010