Many experts agree that regular screening for cholesterol is essential.
What is high cholesterol? How high is cholesterol called severe? How does high cholesterol come down? What should I do if my cholesterol is high? A guide to living with diabetes and high cholesterol? What causes high cholesterol?
Medication, exercise, diet, and positive attitudes are all things people do to cope with high cholesterol.
When Mark was in his 20s, he got his first cholesterol test.
This seems like a good idea. His father died of a heart attack at the age of 50 and his grandfather died of the same thing when he was 60 There is no doubt that the cause of his death was high cholesterol.
However, the results were shocking.
For people his age, his cholesterol levels rose sharply.
Mark learned that he had familial hypercholesterolemia, a genetic disorder that affects about 1 in 250 to 500 people.
This condition impairs the body's ability to remove excess cholesterol from the bloodstream. This information will change his life forever.
Global epidemic
Mark is not alone.
About 71 million adults with trusted sources have high cholesterol levels in the United States (about one-third of all U.S. adults). Globally, 39% of adults over the age of 25 from trusted sources have high cholesterol.
People with high cholesterol levels have twice had a low risk of heart disease from two trusted sources as people. Heart disease is the leading cause of death in the United States and around the world.
Because high cholesterol doesn't show symptoms immediately, it's easy to overlook or overlook.
High cholesterol also often occurs in conjunction with other, more obvious diseases such as obesity or diabetes, which makes it easy to push cholesterol problems aside.
For many, there is simply no outward indication that anything is wrong. As a result, less than half of U.S. adults with high cholesterol from trusted sources are being treated. Less than a third of people have their condition under control.
Mark, a 59-year-old orange county resident, has a comprehensive cholesterol level of 330 mg/dL – well above the health department's recommended maximum of 200 mg/dL. Centers for Disease Control and Prevention Trusted Sources (CDC).
In addition to that, he is in good physical condition. His weight is healthy. He eats well and enjoys softball, tennis and cycling. But despite his healthy lifestyle, his cholesterol levels are still out of control.
A new documentary called "Feelings of the Heart" explores the lives of people around the world like Mark, who live in invisible specters of high cholesterol. Director Cynthia Wade tries to expose this under-discussed issue.
"What we have is not dialogue. We may be exposed to it in a doctor's office, but there's always a feeling of fear, shame, or trepidation, or "Uh, do I really want to know?" Because what if the numbers aren't what they're supposed to be?" She said in an interview with Healthline. "We all do our best, but we all know we can do better, it's a tough conversation, it's a tough thing to see."
Cholesterol in the body
Cholesterol is a fatty substance that the body uses to make a range of chemicals, including estrogen and testosterone.
The body itself produces enough cholesterol to serve these purposes, which means that any cholesterol a person consumes in their diet is unnecessary.
Small amounts of LDL cholesterol, or "bad" cholesterol, dissolve in the bloodstream until the liver digests them and excretes them. However, when these levels are too high, thick plaques of cholesterol begin to form on the walls of blood vessels, which can form plaques.
As these plaques get larger, they shrink the available space within the blood vessels, raising blood pressure and reducing oxygen supply to the heart, brain, and other organs. This increases the risk of heart attack and stroke.
"We know from a number of epidemiological studies that high cholesterol is one of the biggest risk factors for future heart attacks," Nicholas J. Leeper, assistant professor of vascular surgery and cardiovascular medicine at Stanford University, said in an interview. "This is known from landmark studies, such as the Framingham study, which has been conducted for decades."
Genetics plays an important role in altering the chemical pathways that the liver uses to eliminate cholesterol from the body.
Donald Lloyd-Jones, professor and chair of the Department of Preventive Medicine at Northwestern University's Feinberg School of Medicine, explained in an interview: "Our genes establish a range of cholesterol levels that can operate. "Then, our eating patterns determine where we are within that range." In general, it is difficult to break out of this range without changing your diet or not taking your medication. ”
Typically, there are two different types of gene patterns that lead to high cholesterol levels.
Joshua Knowles, an assistant professor of cardiology at Stanford University, said in an interview: "All of us have a tendency to more or less high cholesterol, which is caused by many small genetic variants with very little impact. "Working together, dozens to hundreds of these genetic variants slightly increase your risk of high cholesterol." This is the situation that most of us will encounter. ”
However, Knowles continues that in some rare genes, even a single mutation can have a big impact, such as the gene that causes Mark familial hypercholesterolemia (FH). These genes are dominant, which means that even if you have a copy of the gene, it will be activated.
"If you inherit a bad copy of the gene from one of your parents, you show high cholesterol," Knowles said. "If you inherit a bad copy from both parents, your LDL cholesterol will be surprisingly high."
Managing risk: Diet
"Diet and exercise are the cornerstones of everyone's treatment," Knowles advises.
Together, he said, they can lower LDL cholesterol levels by 10 to 15 percent. For people without FH, this is usually enough.
Maria Bella, founder of Top Balance Nutrition, clinical nutrition coordinator at New York University School of Medicine, and a registered dietitian, believes that a key part of an anti-cholesterol diet is fiber.
"Fiber is found in any fruit, any vegetable and many whole grains," she said in an interview with Healthline. "Fibers form a gelatinous substance in the small intestine, partially blocking cholesterol receptors, promoting the excretion of bile acids and cholesterol, and lowering cholesterol levels."
How do we get enough fiber?
"We talk about eating on a rainbow and consuming six colors of produce a day," she said. "It focuses on interesting things rather than limitations. This way healthy eating becomes very interesting, not sad. ”
Adding fiber isn't the only change you can make in your diet.
Mary G. George, deputy director of science and senior medical officer for science in CDC's Heart Disease and Stroke Prevention Division, offered more advice. Avoid trans fats (found in many long-shelf life packaged cookies and pastries) and saturated fats (found throughout the diary, red meat, and many oils), which promote the body's cholesterol production.
Instead, choose foods that are rich in monounsaturated and polyunsaturated fats, such as nuts and olive oil, which help raise levels of HDL ("good") cholesterol. The American Heart Association (AHA) also reports that good sources of lean protein include low-fat dairy products, poultry, fish, and legumes.
Bella offers important insights into regulating a diet.
"Setting your goals in such a way that you always feel successful so that you're more likely to move on," Bella said. "Focus on setting more realistic goals, like the 80/20 rule: keep 80% of your diet healthy and allow little scammers everywhere."
Managing Risk: Exercise
Dietary changes, while helpful, are not enough. George also urged people with high cholesterol to exercise.
"Regular physical exercise, such as brisk walking, swimming, cycling, and even gardening," she said. "Surgeons recommend that adults do 2 hours and 30 minutes of moderate-intensity exercise per week, and children and adolescents should do at least 1 hour of activity per day."
For those who are busy on weekdays, Bella recommends taking a short break every hour, getting up for a walk or taking a flight of stairs. If done throughout the day, it adds up to the AHA's recommended 40 minutes per day.
"You don't need to go to the gym," she noted.
There are other options for people who don't have the flexibility to work away from their desks or stations every hour.
"The New York Times has a great workout app," Bella advises. "It's a 7-minute app based on high-intensity interval training. If you're traveling, or you're at home, or you can't save money for the gym, this is a great way to work out. All of us have seven minutes to spare. ”
George perfected this suggestion with a few other factors to keep in mind.
"Maintain a healthy weight," she said. "Being overweight or obese raises your cholesterol levels, while losing weight can lower them."
She also advises: "Quit smoking and avoid second-hand smoke." If you don't smoke, don't start. ”
Defense drugs: statins
For most people with high cholesterol levels who do not respond adequately to diet and exercise, the drug of choice is statins.
These drugs inhibit an enzyme in the liver called HMG CoA reductase, which is involved in the production of cholesterol.
Not only does this slow down the rate at which the body produces cholesterol, but it also prompts the liver to produce more LDL receptors, the binding sites that the liver uses to absorb cholesterol from the bloodstream and excrete it from the body.
"It's a bit like a recycling program for LDL cholesterol," Knowles explains. "LDL cholesterol is basically a waste product. You use statins to activate the recovery program. ”
Statins have been around since the 1980s. Many have become generic products, cutting prices to less than $100 a year.
"[Using] statins, we have data that hundreds of thousands of people are carefully monitoring," Lloyd-Jones said. "We know that they have a substantial and significant effect on lowering LDL cholesterol, and conversely, the incidence of heart attacks, strokes, and overall mortality is significantly reduced in each group of patients we studied."
"These drugs are actually very interesting because they seem to have additional benefits that we don't fully understand, beyond their ability to lower cholesterol," Leeper added.
These benefits may soon extend to more people. In 2013, the American College of Cardiology and the American Heart Association (ACC/AHA) jointly released a new set of guidelines to increase the number of people eligible for statins.
According to a report in the Journal of the American Medical Association (JAMA), increasing statin use is actually cost-effective because generic statins are less costly, improved health improves quality of life, and the risk of death is reduced. The researchers used quality-adjusted years of life to quantify health gains.
"We found that the risk thresholds used in the current ACC/AHA guidelines (above 7.5 percent) are worth the money," said Ankur Pandya, assistant professor of health decision science at the Harvard TH Chan School of Public Health and lead author of the guidelines. The study was conducted in an interview with Healthline. "Recommending statin therapy to up to two-thirds of the U.S. population over the age of 40 may be cost-effective (using a 3.0% risk threshold)."
Expanding the use of statins has raised questions about potential side effects.
"Honestly, one of the main side effects of statins is life extension," Knowles said.
About 15 percent of statin users experience muscle soreness, but Knowles says the risk of cancer has not increased and the risk of liver disease is extremely low.
Knowles concluded: "Statins have a bad reputation, but they are very good drugs. They've been around for a long time. ”
Unfortunately for Mark, he belongs to a small group of people with adverse side effects.
Although statins lowered his cholesterol levels by 30 percent, the side effects were too great. He tried almost every statin in the book, and in search of a drug he could tolerate, he even participated in clinical trials of nearly 12 new versions of the drug.
But that didn't help. He experienced not only painful muscle pain, but also emotional disorders.
"I'm usually a very calm, relaxed person," he told Healthline. "When taking statins, I'm sensitive to the small challenges of everyday life, more irritable, and sometimes even angry."
A new option: PCSK9 inhibitors
Although Mark is not currently taking any medication, new options are in sight.
Two new drugs are going through the approval process.
Praluent (alirocumab), produced by Sanofi-Avent and Regenerative, was approved by the U.S. Food and Drug Administration (FDA) on Friday.
Amgen's Repatha (evolocumab) is in the final stages of FDA approval. Repatha was approved for use in Europe on July 21.
These drugs, called PCSK9 inhibitors, block the action of an enzyme called PCSK9, which breaks down LDL cholesterol receptors on the liver. By blocking enzymes, more receptors remain on the liver and more cholesterol can be absorbed from the bloodstream.
Patients taking Repatha or Praluent do not take pills, but inject themselves with the drug. Praluent is administered using a single-dose disposable prefill pen, while Repatha uses an auto-injector. Mark participated in Repatha's clinical trial, and although he was assigned to the placebo group, he still uses auto-injector technology.
"Autoinjectors are very easy to use," he said. "I thought I couldn't inject myself, but with an auto-injector it's nothing."
PCSK9 inhibitors may provide a promising alternative for people who cannot tolerate statins or who are not enough to lower LDL cholesterol levels.
"In the U.S., approximately 25 to 33 percent of patients at high risk for cardiovascular events are unable to adequately reduce their LDL-C levels using statins and/or other currently approved lipid-lowering drugs," said Scott M. Wasserman, vice president of Amgen, in an interview. "Repatha has the potential to provide patients with a treatment option that further lowers their cholesterol levels."
In addition to the upcoming Praluent, Sanofi/Regeneration also sponsored the documentary Heart Felt and set up TakeDownCholesterol.com website.
One possible concern about new drugs, Knowles said, is that because they are under patent protection, they could cost as much as $10,000 a year.
Another question is whether PCSK9 inhibitors can cause long-term side effects.
"They themselves seem to be very effective at lowering LDL cholesterol, especially if you add them to statins, they can make LDL cholesterol levels extremely low," Lloyd-Jones said. "So far, they seem safe. I think it's important that we haven't conducted large clinical trials to determine long-term safety and long-term efficacy in reducing heart attacks and strokes. But in these shorter trials of up to 18 months, we did see a reduction in the incidence of heart attacks and strokes, and we did see very good safety. ”
Both Amgen and Sanofi/Regenerative Are Conducting Such Clinical Trials, which are expected to close in 2017.
Until then, Lloyd-Jones believed that PCSK9 inhibitors should only be used in patients like Mark who needed them the most.
"We should be cautious about when and who we use them for before we get broader data from long-term trials," he said. "My personal feeling is that they should only be used in high-risk patients who for any reason cannot take statins or cannot take them in the most effective doses." I don't think they're ready for a broad prime time until we have long-term data on safety and efficacy. ”
Once the PCSK9 inhibitor was on the market, Mark was excited to try it.
"This new drug looks really great," he said. "As far as I know, I would be happy to take this medication."
What can I do?
Many experts agree that regular screening for cholesterol is essential.
"Just sitting there can't know your cholesterol levels," Lloyd-Jones said. "You have to have a blood test to know what your cholesterol value is."
Adults 20 years of age and older are recommended to check their cholesterol levels every five years. However, people with FH or other risk factors should be tested more frequently. For early detection of FH, all children aged 9 to 11 years should have their levels checked at least once.
Knowing your family history is one of the most important ways to understand your level of risk.
Lloyd-Jones said: "Family history is indeed a key indicator, especially if that family history occurred at a young age in a first-degree relative. "If someone has had a heart attack or stroke in a family under the age of 60, it's definitely something people should be aware of and aware of and share with their doctors."
If family history and cholesterol tests show warning signs, FH's genetic tests can pinpoint problematic genetic mutations in about 60 to 80 percent of cases, Knowles said.
While Lloyd-Jones says statins are necessary for many, he concludes, "You can't expect drugs to replace lifestyle." They have to work together. You should never think, 'Because I'm taking cholesterol medication, I got a free pass.' You have to give it your all. ”
Mark has received his high cholesterol levels.
"Obviously, I wish that wasn't the case, but I also wanted to know if there were some other effects of my high cholesterol that made me who I am now," he said. "While we wait for a medical alternative, please take care of your body in the way you think is healthy. Develop a positive attitude, establish a healthy eating lifestyle, be proactive, [and] connect with others. Find your fun bones to help you cope with life's challenges. ”