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Cholesterol. Get Your Fats Straight!

Medically reviewed by Carmen Fookes, BPharm. Last updated on May 11, 2021.

Confused About The Difference Between Lipids, Fats And Cholesterol?

You're not alone! And it seems a lot of health professionals are confused as well, the way these terms are often bandied about in the same sentence.

Lipids is the umbrella term used to describe compounds that do not dissolve in water and includes fats, oils, lipoproteins, waxes, sterols (including cholesterol), and triglycerides. Lipids is the correct term to describe both fats and cholesterol.

Fats are large molecules with a specific type of structure that allows more energy storage than carbohydrates.

Cholesterols are a unique type of fat with quite a complicated structure.

Confusion Multiplied: Cholesterol Tests Actually Measure Lipoproteins

When your doctor tells you your "cholesterol" levels are high, what he/she really means is that your lipoprotein levels are not within the "normal range". "Cholesterol" tests measure:

  • Total "cholesterol"
  • Low Density Lipoproteins (LDL)
  • High Density Lipoproteins (HDL)
  • Triglycerides

"Cholesterol" is in quotation marks because all of these molecules are made of triglycerides + cholesterol + phospholipids + protein, in varying quantities. They are NOT just cholesterol.

International Guidelines Differ In Recommendations For Cholesterol Monitoring

In actual fact, "cholesterol" blood tests only actually measure total cholesterol and HDL. The LDL and triglyceride component are just calculated using a mathematical equation.

Internationally, some professional bodies have recognized this shortcoming and have changed their guidelines to accommodate this less-than-ideal situation. In people with high triglycerides, measuring non-HDL cholesterol levels may give a better estimate of the risk for heart disease than measuring only LDL. There also appears to be an association between non-HDL cholesterol and recurrent episodes of angina and non-fatal myocardial infarctions (heart attacks) in people with preexisting coronary heart disease.

Your non-HDL cholesterol level is found by subtracting your HDL cholesterol from your total cholesterol. The optimal non-HDL cholesterol level is less than 130 mg/dL (3.37 mmol/L). Higher numbers mean a higher risk of heart disease.

Guidelines on the Management of Blood Cholesterol

The most recent Guidelines on the Management of Blood Cholesterol, issued by the American College of Cardiology/American Heart Association Task Force, were written in 2018, and advise doctors to consider a patient’s blood cholesterol level along with other health and lifestyle factors when assessing and calculating their atherosclerotic cardiovascular disease (ASCVD) risk.

The task force acknowledges that, while there is no ideal target blood level for LDL-C, the general principle that lower is better is recognized. Research suggests an optimal total cholesterol level is about 150 mg/dL, with LDL-C at or below 100 mg/dL. People who have LDL-C levels within this range have a lower risk of heart disease and stroke.

Doctors should use an ASCVD risk calculator to calculate baseline risk. This calculator looks at all the major risk factors (such as age, smoking, high blood pressure, abnormal cholesterol, and diabetes) associated with a particular patient and estimates their probability for developing ASCVD. Other tests, such as a coronary artery calcium test, may also be used if the results are uncertain.

The guidelines advise that high-intensity or maximally-tolerated statin therapy should be given to people with extremely high LDL-C (190 mg/dL or more) or with other conditions that increase their ASCVD risk. The aim is to lower their LDL-C by 50%. Recommendations on when to start therapy for other patients vary, but all patients should undergo lifestyle changes to improve their cholesterol levels.

The Good: Cholesterol Is Vital For Our Survival

To say that cholesterol gets a bad rap is an understatement. Its reputation for being associated with an increased risk of heart attack and stroke means it gets blanketed with the term BAD.

But we wouldn't be ALIVE without cholesterol.

Cholesterol helps our body make bile acids; vitamin D; hormones such as estrogen, progesterone, testosterone, cortisol and aldosterone; and helps form cell walls. Although some cholesterol is obtained from our diet, most is made in the liver and other tissues. So if your "cholesterol" levels are high, there may be a genetic reason for it.

The Bad: High Cholesterol Is Associated With An Increased Risk Of Heart Attack Or Stroke

Experts believe that when there is too much cholesterol in your blood, it builds up on the walls of the arteries. Over time, this causes the arteries to "harden" and also attracts other cells and debris from the blood, narrowing the space that blood has to flow through. Since blood carries oxygen, tissues supplied by the narrowed blood vessel may become starved of oxygen, and cause symptoms such as angina pain or worse, a heart attack if complete blockage occurs.

Coming from a slightly different angle, other experts suggest it is inflammation, not cholesterol that starts this process. Cholesterol just happens to "latch" onto the inflamed blood vessel wall and contributes to the narrowing of the arteries.

Dietary Guidelines. Is Cholesterol OK to Eat?

Even though it seems clear that having high blood cholesterol puts you at risk of heart disease, the whole cholesterol issue itself is more complicated than you think.

The 2020-2025 Dietary Guidelines for Americans, recommend that dietary cholesterol and trans fat consumption be as low as possible without compromising the nutritional adequacy of the diet.

Since trans fats are no longer Generally Recognized as Safe (GRAS), the major source of trans fats in the American diet, partially hydrogenated oils (PHOs) are no longer added to foods. Cholesterol and/or a small amount of trans fat occur naturally in some animal source foods, such as beef, lamb, milk, cheese, and eggs, but these are considered OK to eat as part of a well-balanced diet.

The emphasis of the 2020-2025 dietary guidelines is that it's never too late to start eating better. The four key recommendations are to:

  • Follow a healthy dietary pattern at every life stage: a healthy diet in childhood is likely to have benefits over a lifetime
  • Enjoy nutrient-dense foods and beverages because these provide vitamins, minerals and other health-promoting components. Examples of nutrient-dense foods include lean beef, baked cod, eggs, beans, low-fat yogurt, unsalted nuts and seeds, and fruit
  • Stay within calorie limits when eating nutrient-dense foods and beverages
  • Limit foods and beverages higher in added sugars, saturated fat, and sodium, and limit alcoholic beverages. These foods add calories but few nutrients.

Screening For Cholesterol: When Should It Happen?

All experts agree that cholesterol levels should be measured in ALL people with a history of cardiovascular disease or at high risk of cardiovascular disease. However, the issue of when to screen people WITHOUT symptomatic cardiovascular disease is somewhat contentious.

The AHA recommends all people aged 20 or older, with no previous diagnosis of cardiovascular disease have their cholesterol levels checked every four to six years as part of a cardiovascular (CV) risk assessment.

The USPSTF states that evidence is insufficient to recommend either for or against screening for lipid disorders in children and adolescents 20 years and younger. Men aged 35 and older and women aged 45 and older that are at increased risk for coronary heart disease should be screened for a lipid disorder.

Reasonable options for screening intervals include:

  • Every 5 years
  • More frequently than every 5 years for people who have lipid levels close to those warranting therapy
  • Less frequently than every 5 years for low-risk people who have had low or repeatedly normal lipid levels.

The CDC states that cholesterol should be checked starting early in life and that even children and adolescents should have their cholesterol checked. Cholesterol testing should also be done:

  • Every 5 years for people age 20 or older who are at low risk for cardiovascular disease
  • More frequently than every 5 years for people with cardiovascular disease risk factors.

Targeting Cholesterol: Treatment

Millions of people in America are prescribed treatment for high cholesterol, and statins are the most commonly prescribed medication. Statins work by inhibiting an enzyme called HMG-CoA reductase, which controls cholesterol production in the liver. As a result, blood levels of LDL in the blood are lowered. Examples of statins include:

Simvastatin, lovastatin, and rosuvastatin are also available as the following combination cholesterol-lowering medications:

  • Advicor (lovastatin/niacin extended-release)
  • Simcor (simvastatin/niacin extended-release)
  • Vytorin (simvastatin/ezetimibe)
  • Roszet (rosuvastatin/ezetimibe)

Statins: When To Initiate?

The 2018 Guideline on the Management of Blood Cholesterol recommendations for cholesterol-lowering therapy vary depending on a person's age, their risk of atherosclerotic cardiovascular disease (ASCVD), their LDL-C level, and the presence of other conditions, such as diabetes. Recommendations are summarized as follows.

  • A heart-healthy lifestyle should be recommended to people of all ages. In young people, this reduces the development of risk factors and ASCVD
  • High-intensity or maximally tolerated statin therapy should be used to obtain at least a 50% reduction in LDL-C in people with clinical ASCVD.
  • In people with very high-risk ASCVD, if an LDL-C threshold of 70 mg/dL is not achieved with statin therapy, ezetimibe could be added and then a PCSK9 inhibitor.
  • High-intensity statin therapy should be started in people with severe primary hypercholesterolemia (LDL-C greater than or equal to 190 mg/dL) without calculating 10-year ASCVD risk.
  • Moderate-intensity statin therapy should be started in people aged 40 through 75 years with diabetes mellitus and an LDL-C greater than or equal to 70 mg/dL (≥1.8 mmol/L) without calculating 10-year ASCVD risk.
  • Adults aged 40 through 75 years evaluated for primary ASCVD prevention should have a discussion with their doctor about the benefits and risks associated with statin therapy before starting it.
  • Moderate-intensity statin therapy should be started in people aged 40 through 75 years of age without diabetes mellitus but with LDL-C levels greater than or equal to 70 mg/dL and 10-year ASCVD risk of ≥7.5% if the discussion of treatment options favors statin therapy. Statin therapy is favored in those with risk-enhancing features an intermediated ASCVD 10-year risk of 7.5% to 19.9%. A CAC may be performed in others if a decision about statin therapy is uncertain.
  • Repeat lipid levels 4 to 12 weeks after statin initiation or dose adjustment, and then every 3 to 12 months as needed.

Note that these recommendations differ from the 2016 USPSTF guidelines.

Other Medications To Lower Cholesterol

Several other classes of medicine also lower cholesterol, such as:

PCSK9 inhibitors are a new class of cholesterol lowering medications that dramatically lower LDL cholesterol levels. Examples include alirocumab (Praluent) and evolocumab (Repatha).

In February 2020, bempedoic acid (Nexletol) was approved for use in people who require further lowering of their LDL-cholesterol levels. Bempedoic acid inhibits the synthesis of cholesterol by the liver, and it is used in addition to a low cholesterol diet and the highest dose of a statin. Bempedoic acid is also available in combination with ezetimibe, as Nexlizet.

Self-Help Measures

There is a lot you can do to decrease your risk of cardiovascular disease, regardless of whether or not you are already prescribed cholesterol lowering medication.

  • STOP smoking (if you smoke) and try to avoid second-hand smoke.
  • Eat plenty of vegetables, fruits, and whole foods; avoid processed foods that contain high amounts of salt and trans fats.
  • Get ACTIVE. Exercise every day and sit down less.
  • Keep your weight within a healthy range. Lose weight if you are overweight or obese.
  • If you have diabetes, take your medication as prescribed and always try to keep your blood sugar levels within the normal range.
  • Seek advice about how to limit stress and keep anger in check if you find you are always uptight.
  • Get regular cardiovascular assessments if you have a family history of heart disease or stroke, particularly if your relatives had these conditions at a young age.

Finished: Cholesterol. Get Your Fats Straight!

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