Hypercholesterolemia: Information & Specialists

Cholesterol is a vital fat-like substance. It plays a role in cell structure as well as in the synthesis of hormones, bile acids, and vitamin D.

The body—specifically the liver and the intestines—produces most of the cholesterol it needs. A much smaller amount of cholesterol enters the body through (animal-based) food.

Elevated blood cholesterol levels are considered a risk factor for the development of pathological vascular changes. Excess cholesterol is deposited on the walls of blood vessels and thus contributes to the dangerous formation of plaque (atherosclerosis). In atherosclerosis, the blood vessels become progressively narrower. This can lead to a heart attack or stroke.

High cholesterol levels result from a combination of various factors. In most cases, an unhealthy lifestyle combines with genetically determined disorders of cholesterol metabolism (hypercholesterolemia). An unhealthy lifestyle is defined by poor diet and lack of exercise.

As we age, the liver gradually loses its ability to break down cholesterol. Consequently, blood cholesterol levels rise steadily with age.

Cholesterol-rich foods such as

• meat,
• chicken eggs, or
• dairy products

have been attributed a negative impact on cholesterol levels for decades. To prevent cardiovascular disease, at-risk patients are advised to avoid these foods. Taking cholesterol-lowering medications (statins) is also recommended once cholesterol levels exceed the reference value.

However, the general validity of this reference value—a maximum of 200 mg/dl of cholesterol—is controversial among experts. Whether there is a causal link between a cholesterol-rich diet and the development of atherosclerotic processes is also still under debate. Researchers are not even certain to what extent dietary habits influence cholesterol levels.

Regardless, cholesterol-lowering medications top the list of best-selling drugs on the pharmaceutical market. In this respect, the topic of cholesterol touches not only on medical and scientific interests but also, and particularly, on economic ones.

Cholesterol is a water-insoluble substance. To enable it to be transported through the body by the blood, it is bound to various carrier proteins (lipoproteins).

The most important of these are HDL (“high-density lipoprotein”) and LDL (“low-density lipoprotein”). LDL transports cholesterol to target organs and tissues. Excess cholesterol is transported back to the liver by HDL, where it is broken down.

For this reason, medical professionals now believe that it is not so much the total cholesterol level that matters, but rather the ratio of LDL cholesterol (LDL-C) to HDL cholesterol (HDL-C).

High levels of LDL cholesterol are dangerous. If it is present in larger quantities than needed, macrophages in the blood take up the LDL-C, which is then deposited on the walls of blood vessels.

Over time, the blood vessels can become increasingly narrowed, compromising blood flow. This poses a particular risk of blockage in the coronary arteries (coronary heart disease). Painful angina pectoris attacks or even a heart attack may follow.

High cholesterol levels contribute to the gradual narrowing of arteries © freshidea | AdobeStock

Conversely, the higher the HDL-C level, the greater the protection against atherosclerosis: HDL even directs excess cholesterol to the liver for breakdown, even if it has already been deposited on the walls of blood vessels.

The target ratio of HDL-C to LDL-C is 1:2. If the ratio is less than 1:4, measures to lower cholesterol levels should be taken.

In addition to cholesterol, triglycerides (neutral fats) also play a role in atherosclerotic processes. They are the main component of dietary fats and are stored in the body as energy reserves. They are also transported by LDL.

Excess triglycerides accumulate in the LDL complexes, making them even more dangerous to the blood vessel walls.

As a rule, high cholesterol levels and early-stage atherosclerosis do not yet cause any symptoms.

Therefore, take advantage of the preventive screenings offered by public health insurance providers starting at age 35. During these screenings, blood lipid levels are measured in a laboratory. However, it is not advisable to interpret established general reference ranges too strictly.

Even blood cholesterol levels above 200 mg/dl are not necessarily cause for concern if there are no other risk factors present, such as

• high blood pressure,
• smoking,
• being overweight, or
• diabetes

do not necessarily require treatment right away. The doctor decides whether the measured blood lipid levels should be lowered or not. In doing so, the doctor must always take the patient’s individual overall situation into account.

To treat dangerously high blood lipid levels, it is first and foremost important to eliminate or reduce the risk factors. In particular, this means

• reducing excess weight through a balanced, varied, and low-calorie diet,
• quitting smoking, and
• properly managing diabetes and high blood pressure, if present.

In addition, sufficient physical activity always has a beneficial effect on the HDL-to-LDL ratio. These measures alone almost always cause cholesterol levels to drop significantly “on their own.”

Drug therapy may be necessary if

• there is still no significant improvement in cholesterol levels after several months, or
• hereditary hypercholesterolemia is present.

However, treatment must always be based on a consistent dietary change and weight loss.

Medication for High Cholesterol

The most effective medications for lowering cholesterol levels are cholesterol synthesis enzyme inhibitors (statins). They block a specific enzyme necessary for cholesterol production in the liver. Statins reduce LDL-C levels as well as triglyceride levels and increase HDL-C levels.

Statins are quite controversial in terms of their preventive effectiveness against heart attacks. One reason for this is their rare but serious side effects. Once started, statin therapy is also costly and must be consistently continued for years.

Another commonly used class of medications is fibrates. They lower triglyceride levels and raise HDL-C levels. Substances that inhibit the absorption of cholesterol in the intestine are also frequently prescribed. These include, for example, bile acid-binding resins and plant-based phytosterols.

Cholesterol absorption inhibitors (e.g., ezetimibe) represent a very effective new development. These substances also inhibit the absorption of cholesterol into the bloodstream in the intestines. Their mechanism of action is still largely unclear. When used in combination with statins, they enhance the statins’ effectiveness, allowing for lower statin doses.

Sometimes, none of these medications are effective in lowering extremely high cholesterol levels. In such exceptional cases, apheresis—a procedure in which LDL-C is filtered out of the blood—is necessary.

Side Effects of Treating High Cholesterol with Statins

The most dangerous side effects of statins can include muscle pain or even pathological changes in the muscles (toxic myopathies). In their most severe form (rhabdomyolysis), they lead to

• paralysis of the extremities,
• kidney failure, and
• in exceptional cases, death.

For this reason, the Bayer product Lipobay had to be withdrawn from the market several years ago.

The risk of myopathic side effects also increases with the cholesterol-lowering potency of the medications and their dosage.

Since cholesterol plays a crucial role in fetal development, pregnant women must not take statins.

Statins, like other cholesterol-lowering medications, can also cause a whole range of other side effects, such as

• gastrointestinal symptoms,
• headaches,
• sleep disturbances, or
• skin reactions

. Tolerance to individual medications varies from person to person. These generally moderate side effects can be avoided in some cases by switching to alternative medications.

A balanced diet is anything but a bad idea—not just when it comes to preventing cardiovascular disease. That said, you shouldn’t cut out fats entirely. However, they should not make up more than 30 percent of your diet.

Excessive intake of saturated fatty acids (animal fats) negatively affects cholesterol levels (lowers HDL, raises LDL). Plant-based fats are a better choice. These include

• monounsaturated fatty acids, such as those found in olive oil and canola oil (which raise HDL and lower total cholesterol), and
• polyunsaturated fatty acids, such as those found in sunflower oil, safflower oil, or walnut oil (which lower total cholesterol).

However, even these oils should not be used in excess, as they are very high in calories and can therefore contribute to weight gain.

The following foods contain high amounts of cholesterol:

• organ meats,
• egg yolks,
• butter,
• cheese,
• lard,
• cream,
• fatty meats and sausages

These should be avoided if you have high blood lipid levels or risk factors. Your daily dietary cholesterol intake should not exceed 300 mg.

To summarize once again, here are the most important elements of a “heart-healthy” diet:

• as little animal fat as possible, and more plant-based fats instead, especially monounsaturated fatty acids (olive oil / canola oil)
• less than 300 mg of total cholesterol per day
• as much dietary fiber as possible (>30 g per day) – limited sugar and sugary foods
• Limited alcohol
• Use salt sparingly; instead, use plenty of herbs and spices
• Plenty of fruit, vegetables, and salad
• Drink plenty of fluids
• Take your time when eating

While diet is a very important factor, it is ultimately just one of several building blocks in the prevention of cardiovascular disease. It must be part of a comprehensive approach to a healthy lifestyle.

Above all, this includes developing body awareness. This allows you to recognize how getting plenty of exercise is beneficial not only in the long term but also right away,

• getting plenty of exercise,
• eating sensibly,
• enjoying alcohol only in moderation, and
• completely avoiding nicotine.