High cholesterol: lowering levels naturally by addressing underlying triggers

Symptoms of high cholesterol

Unfortunately, most people who develop hypercholesterolaemia will have no overt signs and symptoms, and the dyslipidaemia is only discovered by chance when the blood is tested during a routine health check.  This is why it is vitally important to have your lipid profile checked regularly, especially if you are:

• Over 40 years of age
• Overweight or obese
• A smoker
• Have excessive alcohol intake
• Consume a diet high in saturated fats and low in fibre
• Lead a sedentary lifestyle, or;
• Have a family history of hypertension or cardiovascular disease

Cholesterol markers – what do they mean?

Hypercholesterolaemia is diagnosed when an elevated level of total cholesterol is found on a blood lipids panel.  Australian guidelines currently recommend a total cholesterol level of less than 4.0mmol/L for people at high risk for the development of cardiovascular disease, or less than 5.5mmol/L for the general healthy population. Elevated total cholesterol however, is not a reliable indicator for cardiovascular disease risk, and the standard medical approach is to test for High Density Lipoprotein (HDL) often referred to as good cholesterol, Low Density Lipoprotein (LDL), HDL:LDL ratio and triglycerides.  If these markers are outside the normal ranges then dyslipidaemia is diagnosed.

Cholesterol is an essential fat produced in the liver and some other tissues. It is then transported in the blood attached to lipoproteins (fat transporting proteins), which is why a lipid profile will usually include the following markers (optimal ranges included):

• High Density Lipoprotein (HDL-c) 1.0-2.0mmol/L
• Low Density Lipoprotein (LDL-c)   2.0-3.5mmol/L
• Total Cholesterol (TC) 3.0-5.5mmol/L
• Non-HDL Cholesterol <3.37mmol/L
• Triglycerides <1.7mmol/L

 
In addition to the standard lipid profile, it is advisable to also measure:

• Apolipoprotein B (APO-B) <130mg/dL
• Very Low Density Lipoprotein (VLDL) <30mg/d

HDL-c

HDL-c is often referred to as “good” cholesterol as it is responsible for transporting cholesterol out of the cells and back to the liver where it is synthesised into bile acids and excreted.

LDL-c

LDL-c is often referred to as “bad” cholesterol as it transports cholesterol from the liver to the cells where it is used in cell structures or to make various hormones.  For this reason LDL-c should not be considered “bad” but recognised as being in excess.

VLDL

VLDL is responsible for transporting triglycerides to the cells of the body to make energy.  If triglycerides are high, VLDL will transport them to adipose tissue where they are stored as body fat.

APO-B

APO-B is another type of protein that is associated with cardiovascular disease, as it is atherogenic – meaning it is able to contribute to arterial plaque associated with cardiovascular disease.  APO-B attaches to other atherogenic lipoproteins such as LDL-c and VLDL to provide structural support to the fatty plaque-like structure. Having a high level of APO-B correlates to a high level of atherosclerotic plaque forming lipoprotein structures in the blood.  Current evidence suggests that APO-B is a better marker than cholesterol, HDL, and LDL to determine cardiovascular disease risk.

However, cholesterol isn’t the problem

A common misconception about cholesterol is that it is “bad” and therefore if you lower cholesterol, you lower your risk for developing cardiovascular disease. Yet the main problem with hypercholesterolaemia is less about the cholesterol and more about these plaque forming lipoproteins that are responsible for the transport of cholesterol and triglycerides around the body.  It is these lipoprotein structures (LDL, VLDL, APO-B) that correlate to cardiovascular disease development.

What causes high cholesterol?

For the majority of the 1.5 million Australians who have high cholesterol, the root cause for elevated cholesterol levels and dyslipidaemia will be dietary. Foods that can cause high cholesterol are those high in saturated and trans-fats, and low in unsaturated plant based fats, or omega 3 fatty acids (fish oils). A diet low in fruits, vegetables and fibre and a high consumption of alcohol will also contribute to elevated cholesterol and an altered lipid profile. However dyslipidaemia should not be considered in isolation, but as part of a complete cardiovascular or cardiometabolic risk assessment.

As with all cardiometabolic disease, the principle underlying problems are dysregulation of the neuro-endocrine and immuno-inflammatory pathways that impacts the cardiovascular system in some way.  The systemic vascular inflammation present makes the vessel tissue fragile and prone to injury. When this occurs, atherosclerotic plaque forms, and immune cells migrate to the site progressively impeding blood flow, and potentially fragmenting the plaque leading to a blockage in a blood vessel and the potential for heart attack and stroke. The risk of this occurring is higher in people with dyslipidaemia.

Familial hypercholesterolaemia

Less commonly, some people may have a hereditary predisposition to high cholesterol, known as familial hypercholesterolaemia, which affects 1 in 250 people in Australia. Familial hypercholesterolaemia prevents the  body from removing low-density lipoprotein (LDL) cholesterol from the  blood which can lead to extremely high cholesterol levels. A diagnosis of familial hypercholesterolaemia can be made using family history, cholesterol levels and genetic testing.  There are also certain populations of people, such as indigenous persons or those of African heritage, who have a hereditary predisposition to developing dyslipidaemia and cardiovascular or cardiometabolic disease.

Factors contributing to high cholesterol

Other than diet, other contributing factors are those common to all cardiovascular and cardiometabolic diseases:

• Genetic predisposition
• Family history of cardiovascular/cardiometabolic disease
• Psychosocial stress
• Sedentary lifestyle
• Obesity
• Smoking
• Inflammation
• Development of insulin resistance

Conventional treatments for high cholesterol

Dietary modification and lifestyle factors such as exercise and smoking cessation are the first line strategies in conventional care for dyslipidaemia.  If these strategies are not successful in correcting the lipid profile within 3 months, then pharmaceutical medications may be prescribed.

The most common class of medications used to treat dyslipidaemia are statins which inhibit a metabolic pathway (HMG-CoA reductase) for endogenous production of cholesterol.  One of the most common side effects of statins is persistent muscle aches and pains. If the use of statins alone is not effective in lowering cholesterol and correcting the lipid profile, or if a patient is unable to tolerate statin medications, other medications such as fibrates, nicotinic acid, or Ezetimibe may be prescribed.

However, treating elevated cholesterol and dyslipidaemia in isolation of a total cardiovascular risk profile can be problematic, as it may not necessarily reduce cardiovascular disease risk.

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