High cholesterol levels are a common concern in our modern world. It is also known as hypercholesterolemia.
This is a type of dyslipidemia or imbalance in the blood levels of lipids.
High cholesterol levels are often paired up with other blood level imbalances.
For example, high triglyceride levels or high blood sugar.
Thus, high cholesterol is often a complex problem that should be solved from different perspectives.
What is Cholesterol?
Cholesterol is a type of fat-soluble particle that is found in the blood. This blood particle has gained a very bad reputation. That is because high levels are associated with atherosclerosis and heart disease. However, we have many different types of cholesterol.
It is highly likely you have heard about “good” cholesterol and “bad” cholesterol. They are also known as high-density lipoprotein (HDL ) and low-density lipoprotein (LDL). Both of them are included in our total cholesterol count.
Bad cholesterol (LDL cholesterol) is a blood particle that transports fat. This process is necessary to create steroid hormones and maintain the integrity of plasma membranes. However, excessive levels of cholesterol build up plaques in the arteries (1).
Good cholesterol, or HDL cholesterol, does the opposite job. It gathers excess fat from the arteries to collect them in the liver. Here, fat molecules can be processed and metabolized according to our individual needs. Thus, higher HDL levels are usually a good thing (2).
So, when we talk about cholesterol problems, we typically refer to high levels of LDL cholesterol and/or low levels of HDL cholesterol.
What Causes High Cholesterol
There are two main types of hypercholesterolemia, according to the leading cause.
1) Primary hypercholesterolemia is an increase in cholesterol levels due to genetic problems. These DNA mutations affect fat carrier molecules.
2) Secondary hypercholesterolemia is the result of an unhealthy diet. It is more severe in cases of liver problems, hypothyroidism, diabetes, and renal insufficiency. Hypercholesterolemia is a silent problem that goes unnoticed for many years. It slowly builds up plaques in the arteries and eventually causes cardiovascular diseases. These patients usually end up having a heart attack or stroke (3).
- Diet: Secondary hypercholesterolemia is much more common. One of the most important causes is having bad dietary habits. In our modern world, it is easy to go for fast food instead of healthier choices, such as fruits and vegetables.
Many other foods increase cholesterol levels. The majority include or make use of animal sources of fat. High LDL cholesterol is prevalent in the occidental world because of the poor dietary choices we have. We also have a sedentary lifestyle and increasingly high levels of stress (4).
- Familial hypercholesterolemia: We mentioned primary hypercholesterolemia is usually due to genetic problems. One of them is called familial hypercholesterolemia.
It is a hereditary issue that causes exceptionally high levels of cholesterol. Thus, it increases the risk of cardiovascular problems in all family members sharing these defective genes. However, early detection and establishing a dietary cure along with treatment and monitoring avoids potential complications (5).
- Medications: Finally, certain drugs cause high cholesterol levels, as well. For example, beta-blockers, diuretics, and other medications used to control blood pressure. Such an increase is not usually dramatic. Moreover, having a healthy diet usually solves the problem.
Symptoms of High Cholesterol
High LDL cholesterol levels may go undercovered for many years. It is often a quiet disease that only gives signs and symptoms when there’s a cardiovascular problem.
Cardiovascular problems after years of high cholesterol levels can be life-threatening. Some of them may even leave permanent effects.
In some patients, having high cholesterol levels for a long time build up fat depositions in the skin. They are called xanthomas or xanthelasmas. They look like yellowish patches right under the skin and may appear in different areas.
Xanthomas are more commonly found in the joint of the elbow, the knees, and hands. It may also appear on the buttocks or the eyelids. Keep in mind they may or may not appear in people with high cholesterol levels. So, it is not a tell-tale sign for every patient (6).
As you will read in the section about complications of high cholesterol, the cardiovascular problems associated with hypercholesterolemia include stroke, myocardial infarction, peripheral arterial disease, and aneurysm of the aorta.
High cholesterol levels may be caused by many other factors along with the diet.
Some health problems cause an elevation of blood cholesterol. They include the following:
Another possible risk factor is menopause and other alterations in sexual hormones.
These physiologic circumstances modulate the way the body handles body fat. Other risk factors include medications that modulate steroid levels or the metabolism of fat.
Doctors use lipid panel tests to diagnose high blood cholesterol. A lipid panel will measure the total cholesterol, good high-density lipoprotein (HDL cholesterol levels), and non-high-density lipoproteins (non-HDL) cholesterol levels in your blood.
Complications of High Cholesterol
The main problem with high cholesterol how it affects the cardiovascular system.
As stated earlier in this article, high cholesterol may lead to cardiovascular events.
However, not every patient with hypercholesterolemia will have the same prognosis. It all depends on mounting cardiovascular risk factors that predispose to cardiovascular disease.
Complications of high cholesterol levels are more likely in patients with the following groups of risk factors (7):
- Non-modifiable risk factors: It means we can’t change them. They include our age and sex, family history and our genetic predisposition to cardiovascular disease.
- Modifiable risk factors: They are cardiovascular risk factors we can change in order to prevent events such as stroke and myocardial infarction. They include habits such as smoking and drinking alcohol, sedentary behavior, and an unhealthy diet. Certain health problems are risk factors, too. For example, diabetes, metabolic syndrome, insulin resistance, and obesity.
- Emerging risk factors: They are risk factors that are still relatively new and under ongoing research. Yet, they are associated with cardiovascular disease, even if we don’t know why. They include high levels of C-reactive protein (CRP), lipoprotein (a), fibrinogen, homocysteine, and having small and dense LDL particles (8).
But why do patients with high cholesterol levels end up having cardiovascular events?
It all starts with changes in the permeability of the blood vessels. This is also known as endothelial permeability. High cholesterol promotes the migration of LDL particles into the wall of the arteries. Then, white blood cells called monocytes feel attracted to the area where LDL particles gather.
They migrate to the subendothelial space. These interact with LDL and become foamy macrophages.
This process gives rise to a vicious cycle of chemical attraction, accumulation, and buildup of plaques in the artery wall. This is known as atherosclerosis.
As a result of atherosclerosis, plaque buildups compromise the lumen of the arteries. There is less available space for circulating blood. As the flow of blood becomes compromised, patients start displaying symptoms.
- calf pain or cramps during exercise (intermittent claudication)
- chest pain as a result of physical activity (angina pectoris)
Note that these are not symptoms of high cholesterol levels. They are symptoms of complicated hypercholesterolemia and may be followed by cardiovascular disease.
If the problem continues, the narrowing of the arteries becomes more severe. The blood flow passing through the narrow artery will increase its pressure, too.
Finally, the plaque will not stand the pressure and rupture, leaving an open structure that attracts coagulation factors and creates blood clots. Even if we don’t have a significant rupture, we can also have erosions of the plaque or calcified nodules.
All of them produce coronary thrombi that migrate to very small arteries of the heart or the brain and cause a heart attack or stroke, respectively (9).
Preventing High Cholesterol
Prevention of high cholesterol is often easier than curing or reducing cholesterol levels when they are already high. There are many different preventative measures we can adopt, but one of the most effective is adopting a healthy diet.
In most cases, all it takes to maintain your cholesterol levels is to lead a healthy diet. Food choices should be adequate for the nutritional requirements of each individual. There should be careful control of how many calories come from carbohydrates, protein, and fat. Moreover, it is essential to understand which types of fat are healthy and which ones should be avoided.
Trans Fats and Saturated Fats
Most types of saturated fat increase the levels of cholesterol. Replacing this type of fat with omega 3 fatty acids might improve cholesterol levels.
Another group of fats that should be avoided is trans-fat. They promote higher LDL levels and significant cardiovascular complications. Processed foods and fast foods are typically high in saturated fat and trans fats.
You can recognize trans fat and most saturated fats quite easily because they become harder at low temperatures.
Other foods with saturated fats include high-fat dairy products and fatty cuts of red meat. Even if all types of oil have saturated fats, some of them contain omega 3 fatty acids, too. Thus, using oils appropriately will help you control LDL cholesterol levels.
In recent years, a plant-based diet has also received much attention, with studies indicating that plant sterols can help to lower cholesterol levels.
While plant sterols help lower LDL cholesterol, they don’t appear to affect your levels of HDL cholesterol or triglycerides.
In one study, 125 participants with moderately elevated cholesterol were randomly assigned to eat either a plant-based diet, low in saturated fat and cholesterol but also rich in fiber, nutrients, and phytochemicals, or a convenience foods-based diet with the same level of total and saturated fat and cholesterol.
After 4 weeks, the participants eating the plant-based diet reduced their total and LDL cholesterol significantly more than those consuming a standard low-fat diet.
A further study published in the Journal of the American Heart Association found that a healthy plant‐based diet was associated with a 19% and 11% lower risk of cardiovascular disease mortality and all‐cause mortality.
Another critical dietary element to lower cholesterol levels is fiber intake. There are two types of fiber, soluble and insoluble. They are different from each other in how they react in the presence of water. Soluble fiber turns into a gel-like substance after absorbing water. The same happens with other liquids, including bile.
Soluble fiber binds to bile and increases the ability to excrete this substance in the feces. Notably, bile has very high cholesterol content.
Since bile is excreted and not absorbed back into the bloodstream, fibers are natural methods to maintain a healthy level of cholesterol in the organism. That’s why they are called bile acid sequestrants.
Besides our dietary choices, we can also prevent high cholesterol levels by living an active lifestyle. It is recommended to maintain an adequate level of physical activity. Doing so will prevent metabolic and cardiovascular disease.
For adults, a minimum of 30 minutes of moderate physical activity for at least 5 days will do the job. At least two days a week should be devoted to resistance training to guarantee good results.
If we do all of this, it is very unlikely we will suffer from high levels of cholesterol (10, 11). The only way would be in case of metabolic disease, genetic problem, or any other risk factor listed above.
Treatments for Cholesterol
Treatment of high blood cholesterol levels depends on the severity of the problem. It also depends on the cardiovascular risk factors of the patient.
In the majority of cases, high cholesterol can go back to normal levels by adopting a healthy diet with the prescriptions we mentioned above.
However, in other cases, cholesterol levels are dangerously high. They may not respond appropriately to dietary modifications. In these cases, we can use a group of cholesterol-lowering drugs called statins.
Statins are by far the most popular and effective cholesterol-lowering medications. When it comes to cardiovascular complications, statins are the perfect solution.
According to a study, they prevented up to 1,500 cardiovascular events in 10,000 patients for 5 years (12). They do it by decreasing LDL cholesterol levels, and we now know that lowering 1 mmol/L of LDL cholesterol will reduce cardiovascular risk by 21% (13).
Side Effects of Statins
However, statins are far from being perfect, and they should be used carefully.
It is because they have side effects and associated risks. For example, they can increase the risk of type 2 diabetes and insulin resistance in obese and overweight patients (14).
They can trigger a rare muscle disorder called rhabdomyolysis, which causes muscle cramps and soreness. This muscle disorder appears in older patients with mounting health conditions (15).
That is why it is important to use statins carefully and under the strict guidance of a doctor. That way, you will make sure that your risk factors are covered, and you’re running enough tests to detect any alteration or side effects before it’s too late.
Cholesterol is an integral part of cell membranes. It is also the building block of steroid protein. But a high level in a blood cholesterol test is not a good thing. Hypercholesterolemia is associated with elevated cardiovascular risk.
An unhealthy dietary pattern usually causes high cholesterol. It is more common in patients with overweight, obesity, and metabolic syndrome. There are genetic causes as well, but they are not so common.
When hypercholesterolemia and cardiovascular risk factors meet, patients have a propensity to suffer a stroke and heart attack. In these cases, high cholesterol promotes the formation of atherosclerotic plaques. They grow asymptomatically for many years. Thus, patients start experiencing symptoms when there are alterations in the cardiovascular system.
There are many ways to prevent high levels of cholesterol in the blood. Since it is asymptomatic, it is recommended to have your cholesterol checked regularly.
The most effective methods are maintaining a healthy weight through a proper diet with plenty of fruits and vegetables. Include olive oil, salmon, and other types of fatty fish with omega 3 fatty acids to your diet. This will also reduce bad cholesterol levels in the blood.
Another way is increasing our physical activity to meet the requirements of 30 minutes, 5 days a week.
As for the treatment of high cholesterol levels, lifestyle modifications are always chosen over medications. In some cases, natural remedies and lifestyle modifications won’t be enough. Then, we will need to use statins. This is a type of cholesterol-lowering medication.
It is beneficial in reducing our cardiovascular risk. However, a doctor should always monitor treatment with statins. This is because statins may increase our risk of type 2 diabetes and has other side effects to consider.