Cholesterol is a type of lipid. It is a waxy, fat-like substance that liver produces naturally. It is vital for the formation of cell membranes, certain hormones (estrogen & testosterone), vitamin D and bile acid.

However, too much of cholesterol can combine with other substances in the blood to form plaque. Plaque sticks to the walls of the arteries causing atherosclerosis.  This leads to coronary artery disease, heart attack or stroke due to blockage or narrowing of the arteries.

There are two types of lipoproteins that carry cholesterol to and from cells, which are low-density lipoprotein (LDL) and high-density lipoprotein (HDL).

Types of cholesterol

• LDL (bad) cholesterol

LDL cholesterol is considered the “bad” cholesterol, because it contributes to fatty build-ups in the arteries (atherosclerosis). This narrows the arteries and increases the risk for heart attack, stroke and peripheral artery disease.

• HDL (good) cholesterol

HDL cholesterol can be thought of as the “good” cholesterol because a healthy level of HDL in the blood may protect us against heart attack and stroke.

HDL also carries LDL (bad) cholesterol away from the arteries and back to the liver, where the LDL will be broken down and passed out from the body. But HDL cholesterol doesn’t completely eliminate LDL cholesterol. Only one-third to one-fourth of blood cholesterol is carried by HDL.

• Triglycerides

Triglycerides are the most common type of fat in the body. They store excess energy from your diet.

A high triglyceride level combined with high LDL (bad) cholesterol or low HDL (good) cholesterol is often linked with fatty build-up within the artery walls, which increases the risk of heart attack and stroke.

Symptoms

High cholesterol levels do not usually cause any symptoms. In most cases it only causes emergency events. For instances, angina (chest pain), high blood pressure, stroke or a soft, yellowish growths or lesions on the skin called xanthomas, fatigue, weight gain, stomach distention and aching pain.

Risk factor

• Age
• Overweight or obese
• Unhealthy eating habits
• Lack of physical activity
• Smoking
• Have a family history of high cholesterol
• Have diabetes, high blood pressure

Treatment of Hypercholesterolemia

• HMG CoA Reductase Inhibitors (Statins)

Statin lowers LDL-cholesterol level by reducing the liver’s production of cholesterol and improve liver’s ability to remove LDL-cholesterol that is already in the blood. It is the first line agent in treating hypercholesterolemia.

Statin should be taken at night. It is contraindicated in pregnancy, lactation, women of child bearing potential and liver failure patient. The most common side effects of statin are muscle aches, gastrointestinal discomfort, headache.

Examples: Simvastatin, lovastatin, atorvastatin and rosuvastatin.

• Cholesterol Absorption Inhibitors

Cholesterol absorption inhibitors selectively blocks intestinal absorption of both dietary and biliary cholesterols and other phytosterols thus reducing the amount of cholesterol that travel from intestine to liver, lowering the amount of cholesterol stored in the liver and hence increasing the amount of cholesterol that can be cleared from the blood.

It can be used in combination with any dose of any statin to further lowering LDL-C if targets are not achieved. Besides, it may be considered as monotherapy in patients who cannot tolerate statins.

There is no major adverse effects have been reported. The most frequent adverse effects are stomachache, diarrhea, headache, fatigue, muscle aches.

Example: Ezetimibe

• Fibric Acid Derivatives (Fibrates)

Fibrates are Peroxisome Proliferator Activated Receptor (PPAR) – α agonist which have an important role in fatty acid oxidation. They reduce serum TG effectively and increase HDL-C modestly. It is limited to the treatment in patient with very high TG levels.

Common side effects are gastrointestinal discomfort, flushing of the skin, dizziness, headache.

Example: fenofibrate (take with meal and swallow whole with water), gemfibrozil (take 30mins before meal)

• PCSK9 Inhibitors

PCSK9 inhibitors are a new class of drugs that lower LDL. It works by inhibiting the binding of PCSK9 to the LDL-receptors. Currently, it is only available as an injection administered subcutaneously at 2-4 weeks intervals. Common side effects are injection-site swelling, flu-like symptoms, nausea and joint pains.

Example: evolocumab, alirocumab

Nutritional Supplements for High Triglycerides and Cholesterol

• Red yeast rice

Red yeast rice is a type of fermented rice. It contains monacolin k, a naturally substance that is similar to lovastatin. Thus, it is able to lower the cholesterol. Studies show that it is able to reduce 22% of cholesterol after about 8weeks of consuming it.

• Fish oil

Fish oil is polyunsaturated fatty acids (PUFA) that only comes from food like herring, mackerel, salmon etc. It is available in liquid or soft gel form. Omega-3 fatty acid in fish oil is able to reduce triglycerides level, prevent the formation of harmful blood clots and improve heart health.

• Oat beta glucan

It is a soluble dietary fibre that will form viscous gel in the stomach before entering the intestines. The gel will then attach to bile acid and remove them from the body. Body will then use more cholesterol to reproduce bile thereby reducing cholesterol in the body.

• Flaxseed oil

Flaxseed oil contains alpha linoleic acid (ALA), a form of omega 3 fatty acids that is found in walnut, flaxseed and chiaseed. It is used to lower the cholesterol level by reducing the LDL-C. Flaxseed oil is available in liquid or softgel form. It is suitable for vegetarian.

• Lecithin

Lecithin is a type of fat that can be found naturally in many foods that’s essential to human health. Most lecithin supplements are made from soybeans. Phosphatidylcholine, a major component of lecithin is responsible for lecithin’s reported health benefits. It is able to reduce LDL and may also raise the level of  HDL.

• Coenzyme Q10 (CoQ10)

CoQ10 is an antioxidant naturally produced by the body that is essential for cellular energy production in mitochondria by converting food into energy. It aids in lowering cholesterol and improving heart health. Cholesterol-lowering statin drugs can reduce CoQ10 production in body, hence CoQ10 supplements are important to restore CoQ10 levels in the body and also to reduce statin side effects (like muscle aches).

• Probiotics

Probiotics are groups of beneficial bacteria that our body needed for good health and vitality. Probiotics,  particularly Lactobacilli plantarum and lactobacilli reuteri can help to reduce cholesterol level by binding with the cholesterol in the intestine to stop it from being absorbed and also produce short-chain fatty acids to prevent cholesterol from being formed by the liver. Probiotics also produce bile acids that help to metabolize fat and cholesterol in the body.

Lifestyle modification

• Have a healthy diet

Reduce the intake of saturated fats and trans fat like red meat and dairy products that are made with whole milk. Choose skim milk, low fat or fat-free dairy products instead. Limit fried food and cook with vegetable oils like sunflower oil, olive oil. Consume more leafy vegetables, fruits and whole grains. Always choose to prepare food at home and if having meals outside; choose food with that is grilled, steamed or boiled.

• Become more physically active

A sedentary lifestyle lowers the level of HDL cholesterol. Less HDL means there’s less good cholesterol to remove bad cholesterol from the arteries. Hence, physical activity is important. It is recommended to exercise 30-45mins per session at least 5 times a week to improve cardiovascular fitness, raise HDL-C and decrease triglycerides level. Aerobic exercise like brisk walking, jogging, cycling and swimming are recommended.

• Quit smoking

Smoking can lower HDL cholesterol. A person with unhealthy cholesterol levels who also smokes will have increased risk of coronary heart disease. By quitting, smokers not only can lower their LDL cholesterol and increase HDL cholesterol but also can help to protect their arteries.  

• Restrict alcohol intake

Alcohol is the macronutrient that contributes to the increase in serum triglycerides. In a person with elevated serum triglycerides, excess alcohol consumption can further exacerbate hyperlipidemia. Thus, alcohol consumption should be restricted to not more than 14 units for male and 7 units for female per week. * 1unit = 250ml of beer = 100ml of wine = 30ml of whiskey

• Weight reduction

Being overweight or obese is linked with increased level of bad cholesterol and decreased level of good cholesterol in the body. A weight loss of 5-10 % is able to enhance total cholesterol and LDL-cholesterol lowering effects, at the same time increase HDL-cholesterol. Therefore, it is important to maintain at normal bodyweight. Recommended BMI for Asians is 18.5kg/m2 –23kg/m2.

References

1. Everything You Need to Know About High Cholesterol. Available from https://www.healthline.com/health/high-cholesterol
2. Cholesterol. Available from https://medlineplus.gov/cholesterol.html
3. HDL (Good), LDL (Bad) Cholesterol and Triglycerides. Available from https://www.heart.org/en/health-topics/cholesterol/hdl-good-ldl-bad-cholesterol-and-triglycerides
4. Understanding Cholesterol Numbers. Available from https://www.webmd.com/cholesterol-management/guide/understanding-numbers
5. Understanding Cholesterol Problems: Symptoms. Available from https://www.webmd.com/cholesterol-management/guide/understanding-cholesterol-problems-symptoms
6. High Cholesterol Risk Factors. https://www.webmd.com/cholesterol-management/high-cholesterol-risk-factors
7. 5th edition of clinical practice guideline : Management of dyslipidemia 2017.
8. Thu Nguyen, Mitchell Karl and Antonello Santini (2017) : Red yeast Rice
9. Yuka Kawakami, Hisami Yamanaka-Okumura, Yuko Naniwa-Kuroki, Masae Sakuma, Yutaka Taketani & Eiji Takeda (2015) : Flaxseed oil intake reduces serum small dense low-density lipoprotein concentrations in Japanese men: a randomized, double blind, crossover study
10. Amouni Mohamed Mourad, Eder de Carvalho Pincinato, Priscila Gava Mazzola, Maricene Sabha, Patricia Moriel, “Influence of Soy Lecithin Administration on Hypercholesterolemia”, Cholesterol, vol. 2010, Article ID 824813, 4 pages, 2010.
11. Robertson R. Do Probiotics Benefit Heart Health? [Internet]. Healthline. 2018 [cited 18 October 2021]. Available from: https://www.healthline.com/nutrition/probiotics-and-heart-health
12. Prevention and Treatment of High Cholesterol (Hyperlipidemia) [Internet]. www.heart.org. 2020 [cited 18 October 2021]. Available from: https://www.heart.org/en/health-topics/cholesterol/prevention-and-treatment-of-high-cholesterol-hyperlipidemia

Diet can have a big impact on your blood pressure. Following a heart-healthy diet can actively reduce your blood pressure, both in short term and long term. The American Heart Association (AHA) recommend following the DASH diet to help manage blood pressure.

DASH Diet

DASH stands for Dietary Approaches to Stop Hypertension. The diet is simple:

1) Eat more fruits, vegetables, and low-fat dairy foods
2) Cut down foods that are high in saturated fat, cholesterol and trans fat.
3) Eat more whole-grain foods, fish, poultry and nuts
4) Limit sodium, sweets, sugary drinks and red meat.

To start the DASH diet, follow these recommendations (based on 2,000 calories a day).

GRAINS: 7-8 daily servings
VEGETABLES: 4-5 daily servings
FRUITS: 4-5 daily servings
LOW-FAT/FAT-FREE DAIRY PRODUCTS: 2-3 daily servings
MEAT, POULTRY, FISH: 2 or less daily servings
NUTS, SEEDS: 4-5 servings per week
FATS, OILS: 2-3 daily servings
SWEETS: Try to limit to less than 5 servings per week
( 1 tablespoon sugar, jelly, or jam)

How Much Is a Serving?

When you’re trying to follow a healthy eating plan, it helps to know how much of certain kind of food is considered a ‘serving’.
One serving is:

– 1/2 cup cooked rice or pasta (GRAINS)
– 1 slice bread (GRAINS)
– 1 cup raw vegetables or fruits (VEGETABLES)
– 1/2 cup cooked veggies (VEGETABLES)
– 1/2 cup fresh fruit (FRUITS)
– 1/4 cup dried fruit (FRUITS)
– 6 ounces of fruit juice (FRUITS)
– 8 ounces of milk (DAIRY PRODUCTS)
– 1 cup yogurt (DAIRY PRODUCTS)
– 1 teaspoon of olive oil (or any other oil)
– 3 ounces cooked meat
– 2 tablespoon seeds
– 1 tablespoon sugar, jelly or jam (SWEETS)

Reducing Salt Intake

Salt has a tremendous effect on blood pressure, mediated by increased extracellular fluid volume and thickening of the arterial walls. This decreases the diameter of the arteries, thereby making it necessary for the heart to pump the blood under higher than normal pressure. Thereby, restricting the salt in one ‘s diet will reduce blood pressure.

The World Health Organization (WHO) recommend reducing intake to less than 5g a day can decrease the risk of hypertension and related health problems. Lowering salt intake can benefit people both with and without hypertension.

Reducing Alcohol Consumption

Moderate to excessive alcohol consumption can increase blood pressure.
In addition, many alcoholic drinks are high in sugar and calories. Drinking alcohol can contribute to overweight and obesity, which can increase the risk of hypertension.
According to American Heart Association (AHA), a maximum of two alcoholic drinks a day for men, and one for women is suggested. The following would count as one drink:

– 12 ounces of beer
– 4 ounces of wine
– 1.5 ounces of 80 proof spirits
– 1 ounces of 100 proof spirits

Reducing Sugar Intake

Sugar can increase your blood pressure in several ways.
Research shows that sugar and sugar-sweetened drinks contribute to weight gain in adults and children. Overweight and obesity predispose people to high blood pressure.
The AHA recommends the following daily added sugar limits:
– 6 teaspoons/ 25g for females
– 9 teaspoons/ 36g for males

Prevention and Management of Hypertension

1) Weight Reduction

Dietary interventions to lower body weight are often recommended for overweight people with mild hypertension. In people with hypertension, weight reducing diet has been shown to reduce blood pressure and body weight. There is evidence that showed a reduction of 1kg in weight relates to 1 mmHg reduction in systolic blood pressure.

2) Increasing Physical Activity

We should suggest patients to actively involved in exercising to help in controlling their hypertension. Exercise can improves blood circulation, contributes to weight control and eventually  lowers the risk of cardiovascular disease as well.
It is recommended that engage in:
– 150 minutes of moderate intensity, aerobic exercise every week
– 75 minutes of high intensity exercise every week.
Exercise at least 5 days per week with 30 mins each is recommended as exercising 30 minutes daily is associated with a reduction of 4 to 9 mm Hg. Examples of suitable activities are walking, jogging, cycling, or swimming.

3) Cessation of Smoking

The nicotine in cigarette smoke is a big part of the problem. It raises your blood pressure and heart rate, narrows your arteries and hardens their walls, and makes your blood more likely to clot. It stresses your heart and sets you up for a heart attack or stroke. While one is smoking, and the effect is sustained for 5-10 minutes after the cigarette is extinguished which means, a cigarette every 15 minutes would keep the blood pressure elevated.
Advise patient to stop smoking to reduce overall cardiovascular risk. Use of Nicorette nicotine gum is one of the options that can suggest to patient who wish to quit smoking.

4) Managing Stress

When stress is excessive and prolonged, it causes trouble in controlling blood pressure. Avoiding or learning to manage stress can help patients to control blood pressure better.
Exercise is a great way to manage stress. Other activities can also be helpful. These include:
– meditation
– deep breathing
– massage
– yoga
– tai chi
These are all proven stress-reducing techniques. Getting adequate sleep can also help reduce stress levels.

5) Developing a Healthy Diet

A heart-healthy diet is vital for helping to reduce high blood pressure. It’s also important for managing hypertension that is under control and reducing the risk of complications. These complications include heart disease, stroke, and heart attack. A heart-healthy diet are those mentioned above (DASH diet).

6) Compliance to Medication

Some antihypertensive medications will have bothersome side effects that leads to poor patient compliance. If a side effect occurs which is not life threatening, encourage the patient to continue the medication but contact the prescribing physician in order to obtain a more tolerable drug therapy. On the other hand, patients should be educated on the importance of adherence to drug therapy to promote better compliance. Patients should understand that the disease is chronic and that continuous therapy is necessary for the prevention of complications.

7) Regularly Checking Blood Pressure

Measuring your blood pressure is the only way to know whether you have high blood pressure. High blood pressure usually has no warning signs or symptoms, and many people do not know they have it.

How To Use A Home Blood Pressure Monitor

1) Measure your blood pressure twice daily.
The first measurement should be in the morning before eating or taking any medications, and the second in the evening. Each time you measure, take two or three readings to make sure your results are accurate.

2) Be still.
When you’re ready to take your blood pressure, sit for five minutes in a comfortable position with your legs and ankles uncrossed and your back supported against a chair. Try to be calm and not think about stressful things. Don’t talk while taking your blood pressure.

3) Avoid food, caffeine, tobacco and alcohol for 30 minutes before taking a measurement
Also, go to the toilet first. A full bladder can increase blood pressure slightly.

4) Make sure your arm is positioned properly. 
Always use the same arm when taking your blood pressure. Rest your arm, raised to the level of your heart, on a table, desk or chair arm. You might need to place a pillow or cushion under your arm to elevate it high enough.

5) Place the cuff on bare skin, not over clothing. 
Rolling up a sleeve until it tightens around your arm can result in an inaccurate reading, so you may need to slip your arm out of the sleeve.

6) Take a repeat reading. 
Wait for one to three minutes after the first reading, and then take another to check accuracy. If your monitor doesn’t automatically log blood pressure readings or heart rates, write them down.