What you need to know about cholesterol

Cholesterol is a fat-like substance called a lipid that’s primarily produced by the liver. If it wasn’t for cholesterol, your brain couldn’t function.

When your doctor tells you about your cholesterol levels, they're actually talking about the levels of several different types of particles that include cholesterol as just one component. These tiny particles are called lipoproteins, because their exteriors are made up of proteins, while the interior contains the lipid cholesterol and a second lipid called triglyceride. (Triglycerides make up most of the fat in your body.)

Your cholesterol test only measures the first two major lipoproteins.

These lipoprotein particles circulate your bloodstream, dropping off molecules of cholesterol wherever they are required—and sometimes where they’re not. “We have four times more than we need,” says Professor Graham, professor of cardiovascular medicine at Trinity College in Dublin. “Nobody quite knows why.”

When that excess sticks to the walls of your arteries it increases the risk of heart problems. If the arteries leading to the brain are involved, it can increase the risk of stroke.

Cardiovascular disease is the number-one killer in Europe, accounting for more than four million deaths a year and cholesterol is responsible for a third of coronary heart disease cases. 

What you should eat to control cholesterol has been a source of confusion. Recent research shows that contrary to previous advice doled out to patients, the cholesterol that you consume contributes only a trivial increase to the cholesterol in your bloodstream. It’s the excess cholesterol your liver manufactures that causes the problems. 

The main culprits are saturated and trans fats, especially in a diet that includes big helpings of red meat and, unsurprisingly, starchy, sugary and processed foods. 

A diet that serves up lots of bread, potatoes, added sugar and white rice increases VLDL, LDL and triglycerides while it decreases good cholesterol. A 12-year Danish study published in 2009 found that substituting starches and sugars for saturated fats in the diet increased the incidence of heart attacks.

Many unsaturated fats, especially those found in olive oil, fatty fish and nuts, actually help lower cholesterol levels. People are more likely to have lower cholesterol levels when they eat a diet rich in fresh vegetables, legumes, whole grains, fish and nuts.

The Mediterranean diet is one such regime, and a Dutch study published in 2010 found that it reduced bad cholesterol. Another study found that a diet high in plant fibre, soya and almonds decreased LDL cholesterol about as well as statins—the gold standard in cholesterol-lowering drugs.

Outi Elovaara, a mother of six from Forssa, Finland, didn’t seem like someone who would have high cholesterol. She maintained a healthy weight, ate well, and she exercised regularly.

However at the age of 51, she suffered a stroke. 

Outi’s cholesterol was more than double what doctors now recommend for someone with a family history of heart disease. She was given prescriptions for a statin to reduce cholesterol, as well as for Plavix, to prevent blood clots.

While statins are often sufficient, some people need additional medications. A drug called ezetimibe (a combination pill with both ezetimibe and a statin) might be prescribed.

According to Dr Anselm Gitt, a cardiologist and researcher in Ludwigshafen, Germany, in a randomised trial of 18,000 high-risk patients, combining ezetimibe with statin treatment brought down LDL cholesterol levels by an additional 10 percent.

Rather than inhibiting cholesterol production, ezetimibe reduces the absorption of cholesterol. This one-two punch can often help people reach safe levels when statins, by themselves, fall short.

What are your options when you need greater cholesterol reduction than you can get with diet alone—and you can’t tolerate statins? Outi Elovaara is among those who experienced severe side effects. “I tried to take the medication, but it was impossible due to joint and muscle pain,” says Outi.

Other concerns are also now coming to light, including a somewhat higher risk of developing type 2 diabetes. Given the life-saving potential of statins, it’s often worth the small risk. But newer—and far more powerful—drugs are in the pipeline.

The answer for people like Outi might come in the form of a genetically engineered medication, designed to help the liver eliminate LDL cholesterol. Several such drugs, called PCSK9 inhibitors, are in the final stages of clinical trials and results have been promising.

None are yet approved for sale, but it's estimated that at least one will be by early 2016. According to Dr Gitt, “If you give this drug, you will bring down the LDL by another 70 percent.” 

Today, Outi relies on plant sterol and stanol food supplements rather than prescription drugs to reduce her cholesterol. These are waxy substances produced by plants that are similar to our own cholesterol, and have been shown to help lower cholesterol levels. As of her last check-up, her total cholesterol was 4.6—better than when she suffered her stroke, but not yet where it should be.

It just goes to show that today’s solutions, and tomorrow’s developments, can help everyone keep their cholesterol at a healthy level.