Living with
High Cholesterol

What is high cholesterol?

High cholesterol, medically known as hypercholesterolaemia, can be part of a broader condition called hyperlipidaemia which occurs when there are too many lipids (fats, like triglycerides and cholesterol) in your blood.
Specifically, when you have high cholesterol, it means that there is too much bad cholesterol (LDL) and maybe not enough good cholesterol (HDL) in your bloodstream.

Cholesterol is a soft, waxy substance made in the liver and transported in the bloodstream to where it is needed for healthy functioning of cells and to produce lipid hormones and bile needed for digestion. However, some foods we eat, particularly animal products, contain dietary cholesterol which can add to the amount of cholesterol found in your bloodstream.

If you have high cholesterol, it could lead to fatty deposits building up in the walls of your arteries, eventually causing atherosclerotic plaques that can cause hardening and narrowing of your arteries.

High cholesterol is a chronic condition that requires long-term management to avoid serious health complications like heart attack and stroke.

How do you know you have high cholesterol?

People with high cholesterol usually have no symptoms to let them know that their cholesterol levels are elevated.
Therefore, it is important that your doctor checks your cholesterol levels, especially if you have any of the following risk factors:

• Have coronary artery disease or have experienced a previous heart attack or stroke
• A family history of high cholesterol or other hyperlipidaemias
• High-fat diet (specifically if you eat a lot of red meat, hard fats like butter, or fried foods)
• Overweight or obesity
• Sedentary lifestyle/physical inactivity
• Smoking
• Age (particularly if you are a woman post menopause)
• Hypertension, diabetes or kidney disease
• Frequent and excessive alcohol consumption
• As high cholesterol can cause coronary artery disease, some people with high cholesterol may experience symptoms such as an angina (chest pain or discomfort), shortness of breath and cold hands and feet.

What are the different types of cholesterol and how are they measured?

It is suggested that your doctor or healthcare provider checks your cholesterol levels routinely (at least every four to six years if you are 18 years or older and at least once from six to 17 years of age). If you are over 40 years or have any risk factors for high cholesterol, your doctor will recommend more regular testing.

Your doctor will probably need to do a blood test called a lipid panel to measure your cholesterol levels. You will need to fast – not eat or drink anything, except water – for nine to 12 hours before blood is drawn for the test, that will show the amount of the following in your blood:

• Total cholesterol: This includes both low-density lipoprotein (LDL) cholesterol and high-density lipoprotein (HDL) cholesterol.
• LDL cholesterol: This is the main source of cholesterol build-up and atherosclerosis in arteries and is therefore known as “bad cholesterol”.
• HDL cholesterol: HDL helps remove LDL cholesterol from your arteries and is therefore known as “good cholesterol”.
• Non-HDL: This figure is calculated by subtracting your HDL level from your total cholesterol. This number will include the amount of LDL and other types of cholesterol (such as VLDL or ‘very-low density lipoprotein’) present in your bloodstream.
• Triglycerides: This is another form of fat in your blood that, if elevated, increases your risk for heart disease.

The lipoprotein, LDL is made in the liver and consists of cholesterol attached to a protein. The protein enables cholesterol to be transported from the liver in the blood to where it is needed. HDL, on the other hand, is a transporter molecule that collects cholesterol from cells and returns it to the liver to be broken down.

The numbers to know:

Healthy cholesterol levels are specific for your age and gender; however, generally, healthy blood lipid levels are taken as:

• Total cholesterol less than 5 mmol/l
• LDL cholesterol level less than 3 mmol/l
• HDL cholesterol level greater than 1.2 mmol/l for women and 1.0 mmol/l for men
• Triglyceride level less than 1.7 mmol/l

What causes high cholesterol?

According to the Heart and Stroke Foundation of South Africa, about one in four adult South Africans have a high total cholesterol, while 30 % have a high LDL level and 50 % have low HDL levels.

The major risk factors for high cholesterol include: existing cardiovascular disease or stroke, a family history of high cholesterol or hyperlipidaemia, being overweight, a high-fat diet, being physically inactive, smoking, older age, a history of certain chronic metabolic conditions – especially hypertension and diabetes – and excessive alcohol consumption.

Specific detail on how these factors contribute to high cholesterol are given here:

• Because high cholesterol causes atherosclerosis (deposits of fat in the wall of blood vessels that can form large plaques leading to hardening of the vessels), it means people with the condition are at greater risk of having their arteries narrow or plaques breaking off and causing clots in the bloodstream. This can cause the arteries of the heart to become occluded and the muscle of the heart to be deprived of oxygen and nutrients (a condition known as coronary artery disease) which can cause heart attack. Arteries supplying the brain can also become occluded, causing stroke.
  Therefore, if you have existing coronary artery disease or have had a stroke previously, you may already have had high cholesterol.
• Genetic Influences: Specific genes control cholesterol metabolism and high cholesterol may therefore be inherited. Some people have high cholesterol due to a genetic condition called familial hypercholesterolaemia.
  If one of your parents, grandparents, siblings or other close family members (like first cousins, aunts or uncles) have high cholesterol, make sure your doctor does a full lipid panel to screen you for high cholesterol as well. Familial hypercholesterolaemia can even affect young children, so it is important that cholesterol levels in young people with a family history of high cholesterol are also tested.
• A high-fat diet: Saturated and trans-fats are broken down into LDL cholesterol in the liver. A diet in these fats increases total cholesterol and LDL levels. Saturated fats are particularly found in fatty, red meats and hard fats like butter, as well as in hard dairy products, chicken skin, cream, coconut oil and fried foods.
• Overweight or obesity: If you are overweight, it is more likely that you have higher levels of triglycerides and LDL and lower levels of HDL.
  This is all part of what is called metabolic syndrome that occurs when you are overweight and a range of metabolic changes have occurred in your body as a result, including changes to lipid metabolism.
  However, people at a healthy weight can also have high cholesterol and will therefore need to have their cholesterol levels monitored as well.
• Lack of physical activity: If you are not physically active, your amount of good cholesterol, HDL, tends to decline, causing more LDL to accumulate in blood vessels.
• Smoking: The chemicals in tobacco smoke (including nicotine) damage blood vessels and increase atherosclerosis, putting you at higher risk of heart disease and stroke.
  Tobacco smoke may also decrease HDL levels.
• Age: Cholesterol levels increase with age for both men and women (although, as stated, high cholesterol can occur in children with a family history). However, postmenopausal women experience higher LDL levels once oestrogen levels start declining.
  Oestrogen is the hormone that controls menstruation and fertility in a women’s childbearing years. Oestrogen protects against LDL as it increases HDL levels. Being on some forms of hormonal oral or injectable contraceptives may also increase cholesterol levels in women.
• Chronic Diseases: If you have certain chronic conditions, like diabetes, hypertension or kidney disease, you are at greater risk of having high cholesterol. This is because these conditions may be linked to metabolic syndrome where lipid metabolism changes and cholesterol levels increase.
• Alcohol: Not only does excessive alcohol consumption damage the heart and blood vessels, but it also directly increases the amount of triglycerides and cholesterol in your blood.

Living and managing

You can reduce your risk of developing high cholesterol or manage your cholesterol levels through certain lifestyle modifications. However, some people may also have to take medication to ensure their cholesterol stays within healthy levels.

By working closely with your doctor, you can manage your cholesterol levels by focusing on these specific key areas:

1. Eat a healthy diet low in fat and high in fibre
   This is crucial to reducing your cholesterol levels. A diet high in saturated and trans-fats increases total cholesterol and LDL levels. Saturated fats are found in fatty, red meats and hard fats like butter, but also in chicken skin, hard dairy products, cream and coconut oil, while fried foods are high in trans-fats. These are the type of fats that will “clog up arteries” and increase the risk of heart attack and stroke. Therefore, it is very important that you replace these with foods that are high in healthier mono-unsaturated and polyunsaturated fats such as plant oils, peanut butter, nuts and seeds, avocado, fish and lean chicken.
   Try to avoid frying food by using healthier cooking methods like baking, boiling and roasting.
   Increasing dietary fibre intake is also known to reduce cholesterol levels. You should aim to incorporate more foods high in soluble fibre into your diet. Foods high in soluble fibre include high-fibre wholegrains, oats, rice, legumes (lentils and beans), vegetables and fruits. It is recommended that you eat five fruit and vegetables per day to stay healthy.
   See Cooking from the Heart for delicious, heart-healthy recipes and about how to make healthier meat choices, use healthy cooking methods and how to incorporate more fruit and vegetables into your diet.
2. Exercise
   Try to keep as active as possible. You don’t have to join a gym do this; instead, just take regular walks, ride a bike or dance along to the music on your radio.
   Your goal should be 30 minutes of moderate activity (makes you sweat and your heart beat a little faster) most days of the week. Also include doing some vigorous/high-intensity aerobic exercise (like running, skipping, swimming and dancing) which will help increase good HDL levels even more.
   Regular physical activity also reduces the risk of heart disease and stroke and helps alleviate stress.
3. Try to achieve and maintain a healthy weight
   Losing just 2-5 kg of weight can significantly reduce elevated cholesterol levels. However, cholesterol levels start decreasing with smaller losses, but greater reductions are seen with the more weight you lose.
4. Take your medication as prescribed
   To reduce your cholesterol levels, your doctor may also recommend you take medication in conjunction with changing certain lifestyle habits. Taking medication is NOT a replacement for healthy lifestyle changes though!
5. Know your numbers
   If you have high cholesterol, your doctor or healthcare provider must review your cholesterol levels often to assess your risk for heart disease and stroke and to see if you require medication to help reduce levels along with further lifestyle changes.
6. Stop smoking
   Talk to your doctor about ways to quit smoking, as tobacco smoke increases your risk of atherosclerosis and resulting heart disease and stroke.
7. Limit your alcohol consumption
   As excess alcohol consumption damages the heart and blood vessels and increases cholesterol levels, you will need to consider limiting your alcohol intake to manage your cholesterol levels and risk of complications effectively.
8. Manage stress
   When you are stressed, your heart rate and blood pressure go up – both of which is bad for the heart. You might also not manage your cholesterol levels well and forget to eat right, exercise or take your medicines when you are anxious.
   Find ways to relieve stress like practising meditation, mindfulness or yoga.

What treatment is available for high cholesterol?

The most common type of medication your doctor may prescribe is a statin. Statins reduce the amount of cholesterol produced in the liver.

While statins are generally safe, side-effects like muscle weakness and mental fogginess may occur. If side-effects do occur, do not stop taking your medication but report the side effects to your doctor or other healthcare provider as soon as possible, so that they can advise you on how to safely alter the dosage you take or change the type of medication you are on. People with liver disease, over 80 years old or with neuromuscular disease (like ALS) or hypothyroidism are at increased risk of experiencing side-effects and may not be suited for statin treatment.

*Do not drink grapefruit juice if you are taking statins, as it contains enzymes that will break down the drug and prevent it from producing its cholesterol-lowering effect.

What are the complications associated with high cholesterol?

If your cholesterol levels are high, over time you will get damage to your blood vessels through atherosclerosis. This can cause:

• Coronary artery disease which could angina or cause heart attack
• Stroke
• Peripheral artery disease (pain, numbness or tingling in the legs and extremities)
• Other metabolic syndromes like diabetes.