Cardiovascular disease (CVD) kills more than five million Europeans each year (WHO), in the ratio of 55% women : 43% men.

Cardiovascular conditions result in direct and indirect costs that exceed €192 billion annually in the countries that comprise the European Union. A key contributory factor is high cholesterol. It is estimated that 20% of Europeans have elevated cholesterol (EU-27 approx. 500 million) which equates to approximately 100 million. CVD is the leading cause of death in postmenopausal women, and in fact more women die from heart disease and stroke than from the next five causes of death combined, including breast cancer. This is particularly pronounced in women that smoke, are overweight, and do not take regular exercise.

Cardiovascular disease (CVD) is the leading cause of death in both men and women, yet the extent of the problem in women is frequently underestimated and, compared with men, women are less likely to be offered interventions, are less likely to be represented in clinical trials, and have a worse prognosis.

This graph shows the percentage of population affected by CDV:




The following graph shows high cholesterol levels for men and women in England in 2003:




What Is Cholesterol?

Cholesterol is a lipid (fat) and is vital for the normal functioning of the body. Only a small amount of the cholesterol in the body comes from our diet. About 20–25% of total daily cholesterol production occurs in the liver. Other sites of high synthesis rates include the intestines, adrenal glands and reproductive organs. Cholesterol is recycled. It is excreted by the liver via the bile into the digestive tract. Typically about 50% of the excreted cholesterol is reabsorbed by the small bowel back into the bloodstream.

Cholesterol is present in the membrane of every cell in the body. It insulates nerve fibres, and is an essential building block for hormones, such as the sex hormones and the hormones made and released by the adrenal glands. Cholesterol also enables the body to produce bile salts, converts sunshine to vitamin D, and is important for the metabolism of fat soluble vitamins including vitamins A, D, E and K.

Without cholesterol, the body wouldn't work; however, too much cholesterol in the blood increases the risk of both coronary heart disease and disease of the arteries.

As cholesterol is not water-soluble it must bind to special proteins before it can be carried in the bloodstream. These ‘packages’ are called lipoproteins. There are two main types of lipoproteins: Low-density lipoprotein (LDL) and High-density lipoprotein (HDL).

Low-density lipoprotein (LDL)

This is often known as ‘bad cholesterol’ and is thought to increase arterial disease. It carries cholesterol from the liver to the cells. Most of the body's cholesterol (around 70%) is transported in this form. It consists mainly of fat, with not much protein. High levels of LDL are associated with an increased risk of cardiovascular disease as LDL causes cholesterol to be deposited in the blood vessels.

High-density lipoprotein (HDL)

This is often referred to as 'good cholesterol', and is thought to prevent arterial disease. It takes excess cholesterol away from the cells and back to the liver, where it is either broken down or is passed from the body as a waste product. A small amount of cholesterol is transported as HDL, which is mostly protein and not much fat. As HDL helps prevent cholesterol building up in the blood vessels, there is a decreased risk of heart disease.

When we eat fats in food they form triglycerides that are absorbed into the blood and either burned for energy or deposited into the body’s fat stores. High levels of triglycerides often go together with low levels of good (HDL) cholesterol or high levels of bad (LDL) cholesterols.

Effects of High Cholesterol

Abnormally high cholesterol levels (hypercholesterolemia) – that is, higher concentrations of LDL and lower concentrations of functional HDL – are strongly associated with cardiovascular disease because these promote atheroma development in arteries (atherosclerosis).

This disease process leads to myocardial infarction (heart attack), stroke, and peripheral vascular disease. This is because narrowing of the coronary arteries that bring blood to the heart can stop or slow down the flow of blood to the heart, which means that the amount of oxygen-rich blood is decreased (coronary heart disease). Sometimes the plaque build-ups can burst, releasing cholesterol and fat into the bloodstream, which may then cause the blood to clot. Such clots can block the flow of blood, which may then cause angina or even a heart attack.

Managing High Cholesterol

As there are usually no obvious symptoms of raised cholesterol, a simple blood test is required to measure the amount of cholesterol in the blood (in millimoles per litre). In particular, it's the balance of the different types of lipoproteins, rather than the overall total cholesterol level, that matters.

Guidelines are as follows:

Total cholesterol (U.S. and some other countries)	Total cholesterol* (Canada and most of Europe)
Below 200 mg/dL	Below 5.2 mmol/L	Desirable
200-239 mg/dL	5.2-6.2 mmol/L	Borderline high
240 mg/dL and above	Above 6.2 mmol/L	High

LDL cholesterol (U.S. and some other countries)	LDL cholesterol* (Canada and most of Europe)
Below 70 mg/dL	Below 1.8 mmol/L	Optimal for people at very high risk of heart disease
Below 100 mg/dL	Below 2.6 mmol/L	Optimal for people at risk of heart disease
100-129 mg/dL	2.6-3.3 mmol/L	Near optimal
130-159 mg/dL	3.4-4.1 mmol/L	Borderline high
160-189 mg/dL	4.1-4.9 mmol/L	High
190 mg/dL and above	Above 4.9 mmol/L	Very high

HDL cholesterol (U.S. and some other countries)	HDL cholesterol* (Canada and most of Europe)
Below 40 mg/dL (men) Below 50 mg/dL (women)	Below 1 mmol/L (men) Below 1.3 mmol/L (women)	Poor
50-59 mg/dL	1.3-1.5 mmol/L	Better
60 mg/dL and above	Above 1.5 mmol/L	Best

Triglycerides (U.S. and some other countries)	Triglycerides* (Canada and most of Europe)
Below 150 mg/dL	Below 1.7 mmol/L	Desirable
150-199 mg/dL	1.7-2.2 mmol/L	Borderline high
200-499mg/dL	2.3-5.6 mmol/L	High
500 mg/dL and above	Above 5.6 mmol/L	Very high

There are many factors that may cause raised cholesterol; however, the most common cause is eating too much fat and in particular too much saturated fat. High intakes of saturated fat can raise the ‘bad’ (LDL) cholesterol levels.
However, if the blood test does show raised cholesterol, the GP usually discusses the problem as the overall risk is determined by a combination of factors such as an underactive thyroid gland, age, gender, family history, diabetes, obesity, high blood pressure, drinking a lot of alcohol, smoking and some rare kidney and liver disorders.

Generally there are two ways to help lower high cholesterol.

The first is lifestyle issues, including changing the diet, weight management, and increasing exercise. 80% of all cardiovascular disease is preventable with such changes.

The second is to combine lifestyle changes with cholesterol-lowering medicines.

Lifestyle:

Healthy eating can reduce cholesterol. The diet should be low in saturated fats in particular (less than 7% of the daily calorie intake), and low in fat overall. Biscuits, cakes, pastries, red meat, hard cheese, processed meats and butter all tend to be high in saturated fats.
Instead, low-fat dairy products, semi skimmed or skimmed milk, low fat yoghurts and mono or poly-unsaturated spreads should be substituted.
Meats should be grilled or steamed instead of fried or roasted. If roasted, the meat should be placed on a rack to allow the fat to drain off. If frying, a vegetable oil, such as sunflower, should be chosen. The skin should be removed from poultry. Soya products have been shown to reduce cholesterol. So using some soya products in place of fatty meat is a good idea.

Research has shown that soya protein and also soy isoflavones have a positive effect on heart health. However clinical trials have shown that a combination of soya protein, soya phospholipids, soya fibre and soya germ delivering a guaranteed level of iosflavones is more than twice as powerful in reducing LDL and triglyercides than soya protein alone.

Fish, especially oil rich fish such as sardines, salmon, mackerel, pilchards and trout, contain Omega-3 fatty acids which are thought to lower LDL.

Some foods contain cholesterol. These foods include eggs, prawns and offal such as liver and kidneys. This type of cholesterol is known as dietary cholesterol and it has a much lower effect on blood cholesterol than saturated fat in the diet. So, unless suggested by the GP, these foods do not have to be reduced.

It's also important to eat plenty of fibre, especially soluble fibre. Found to reduce bad cholesterol by up to 5%, soluble fibre occurs in oats, pulses and certain fruits and vegetables. It works by reducing the absorption of cholesterol in the intestines.

Foods containing substances called plant sterols or stanols may help to lower cholesterol. Rich natural sources include rice bran, avocado oil, wheat germ and extra-virgin olive oil. They work by reducing the absorption of bad LDL cholesterol from the intestine, without affecting the good HDL cholesterol.

Being overweight is also a factor in high cholesterol, so an excess weight loss plan may help to reduce LDL levels and increase HDL levels.

Increasing physical activity may also enhance the cholesterol-lowering effects of the diet. A daily 30 minute moderate / vigorous workout is recommended. It is also important to try to reduce the waist size.

As high cholesterol can increase the risk of heart disease, any additional risk of developing heart disease should be addressed, e.g. stopping smoking and drinking alcohol moderately.

Lastly, plenty of sleep is also recommended, as is trying to keep the blood pressure at a normal level.

Medicines:

GPs may prescribe cholesterol-lowering medicines if a person already has heart disease, or are at high risk of getting it because of other risk factors.

The main group of medicines for lowering cholesterol are statins. These have been shown to reduce the risk of heart disease, stroke and vascular mortality.

Aspirin is often prescribed but this should not be given to people under the age of 16.

GPs may also consider Hormone Replacement Therapy for menopausal women. Given the loss of endogenous oestrogen at menopause it was hypothesized that exogenous oestrogen could have a similar effect. However, research studies, in particular the Women's Health Initiative and the Million Women Study, have found that HRT offers no protection and has been shown to increase the risk of heart attack, especially in the first year of use, and to increase the risk of ischaemic stroke.