Key learning points:
– Cholesterol screening needs to be a public health priority
– Different approaches need to be trialled to try to increase take-up of the health check programme
– More informed advice and support should be offered by the community team after cholesterol test results are given
Cholesterol is an essential fat, which is made predominantly in the body by the liver, but is also found in some foods (eg, egg yolks, butter, cheese, shellfish and cream). It plays a vital role in how every cell works and is also needed to make vitamin D, some hormones, and bile for digestion. However, too much cholesterol in the diet increases the risk of heart disease and strokes.
Cholesterol is carried in the blood attached to proteins called lipoproteins. There are two main forms: low density lipoprotein (LDL) and high density lipoprotein (HDL). These lipoproteins have fat on the inside and proteins on the outside. LDL cholesterol is referred to as bad cholesterol because too much is unhealthy. Whereas, HDL is often referred to as good cholesterol because it is protective against an imbalance of ‘bad’ cholesterol. Good cholesterol picks up excess cholesterol from the tissues and arteries and transports it back to the liver to be broken down.
If cholesterol builds up it can lead to the formation of plaque in the coronary arteries. Plaque consists of fat, cholesterol, calcium and other substances. If the plaque constricts the blood vessels then the risk of atherosclerosis, heart attack, stroke, transient ischaemic attacks and peripheral arterial disease increases.1
What should cholesterol levels be?
Blood cholesterol is measured in units called millimoles per litre of blood, often shortened to mmol/L.
The government recommends that total cholesterol levels should be:
– 5 mmol/L or less for healthy adults.
– 4 mmol/L or less for those at high risk.
The government recommends that levels of LDL should be:
– 3 mmol/L or less for healthy adults.
– 2 mmol/L or less for those at high risk.
An ideal level of HDL is above 1 mmol/L. A lower level of HDL can increase a person’s risk of heart disease.
The ratio of total cholesterol to HDL may also be calculated. This is the total cholesterol level divided by the HDL level. Generally, this ratio should be below four, as a higher ratio increases your risk of heart disease.
However, cholesterol is only one risk factor and the level at which specific treatment is required will depend on whether other risk factors, such as smoking and high blood pressure, are also present.
Factors that affect levels of cholesterol?
Raised or unhealthy patterns of blood cholesterol affect many people. Many factors play a part including:
- Genes inherited from your parents.
– Diet and lifestyle.
– Medical history.
Having unhealthy cholesterol levels alongside other risk factors for heart and circulatory disease, such as smoking or high blood pressure, can put you at a very high risk of early heart disease.
The picture is more complicated than it seems, as it’s not just a matter of avoiding certain foods to ensure lower levels of cholesterol in the blood.
Saturated fats have ranging impacts on cholesterol, and, to complicate things even more, the same amount of fat in cheese does not elevate cholesterol in the same way as it does for example in butter. This may be because there are other nutrients in cheese such as proteins and calcium that result in a lowered proportion of cholesterol. Research is still needed in this area.
The health check programme
This NHS population-wide prevention programme was introduced during 2009, with the aim of measuring and managing cardiovascular risk in the 40-74 age group. NHS health checks are routinely offered free of charge to those within this age group. It is the first programme in the world tackling the prevention of heart attacks and strokes.
According to the first analysis of the NHS health check programme, run by Public Health England (PHE), major cardiovascular incidents are being reduced.2 Over the first five years the programme has prevented 2,500 cases, because patients have received treatment. In addition, the checks are diagnosing conditions commonly linked to heart disease, for example high blood pressure and chronic kidney disease. Queen Mary’s University of London3 led a study which found that people in the most deprived areas and in the highest risk groups were most likely to attend checks. Those most at risk are black and minority ethnic groups. Despite this, more should be done as only 48% of those people who were invited actually attended.
Responsibility for the health checks transferred from Primary Care Trusts to local authorities in 2013, and data analysis4 shows that take up stayed the same – at around 48% – during this transitional period. Local authorities and public health departments need to do more to encourage people to take up their invitation for screening.
However, a study undertaken in Ealing5,6 found that the workload for managing the health check initiative is substantial, with a range in the variety of risk factor recordings. Some practices did not record ethnicity for example, which is closely linked to risks of cardiovascular events. If data collection is poor, then future planning of resources will be compromised. With the increasing pressure on local authority budgets it is important that there is a clear cost/benefit to the programme.
Treatment and prevention
Firstly, it is important to try to lower cholesterol without medication, with changes to diet and increased exercise. Eat a mainly plant-based diet.7 Try to swap high saturated fatty foods for high unsaturated fat foods (eg, soya foods, oily fish, almond milk and wholegrains).
Regular exercise can help to lose midriff fat, which in turn can boost HDL and lower LDL and triglycerides. Any exercise that causes sweat and slight breathlessness is best. Around 30 minutes of such exercise should be taken daily. If you haven’t time then a pedometer can help, with an aim to take at least 10,000 steps a day.1 Alcohol and smoking also increase cardiovascular risks.
The standard medication prescribed for cholesterol lowering is one of the family of medicines known as statins.
Statins are the standard medication prescribed for cholesterol lowering, they inhibit an enzyme called HMG-CoA reductase, which controls cholesterol production in the liver. The medicines act to replace the HMG-CoA that exists in the liver, thereby slowing down the cholesterol production process. Additional enzymes in the liver cell sense that cholesterol production has decreased and respond by creating a protein that leads to an increase in the production of LDL receptors. These receptors relocate to the liver cell membranes and bind to passing LDL and VLDL (very low density lipoprotein). The LDL and VLDL then enter the liver and are digested.
Many people who begin statin treatment do so in order to lower their cholesterol level to less than 5 mmol/l, or by 25-30%. The dosage may be increased if this target is not reached. Treatment with the statin usually continues even after the target cholesterol level is reached to sustain atherosclerosis prevention.
All medications can have side effects, but statins are generally well tolerated, with minor problems such as headaches, muscle pain and possible flushing. There is also a small increased risk of developing diabetes. Statins have had their share of bad press, but are effective and should be used if other measures like dietary changes do not result in acceptable cholesterol levels. All patients must have a liver function test before starting statins, to ensure that the liver can metabolise waste products adequately. Some studies point to the importance of avoiding unnecessary lipid/cholesterol testing.8 Other studies have looked at the cost/benefit of using certain statins.
The study carried out be Petty et al9 concluded that the less expensive generic statins should be used in preference to the more expensive, as health outcomes were similar.
Foods that lower cholesterol
Foods such as fruit and vegetables and soya foods for example, should be incorporated into the diet if possible.
Unsweetened and unsalted nuts are the best option to avoid added sugar and salt. Plant sterols and stanols are compounds that help lower ‘bad’ LDL cholesterol. These are found in the foods such as – wholegrains, plant oils, vegetables, nuts and fortified foods.
Are there gaps in care?
For my personal experience, following my recent NHS health check I was told that I had raised cholesterol.
This was the first NHS check that I have had, so I have no idea how long the cholesterol level has been raised. It would have been helpful to have more information. I was told that my blood reading was 5.7 mmols/L but I would have been interested in knowing the ratio of ‘good’ and ‘bad’ cholesterol too.
A leaflet about the different types of cholesterol and some nutritional advice would have been welcomed. The nurse told me to stop eating butter and cream, but a leaflet about the best foods to consume would have provided more factual advice, including some information about the foods that lower cholesterol levels. We need cholesterol in a certain amount to ensure healthy functioning of the body, for example good digestion and to manufacture vitamin D. If a person becomes anxious and avoids foods there is the risk that they will become deficient in cholesterol, rather than achieve a healthy equilibrium.
Screening and managing cholesterol levels is a public health priority. It is interesting how cholesterol plays such a vital part in the healthy functioning of the body and is present in every cell.
Public health bodies need to look at the information they are giving and help people to lead a healthy lifestyle and make well informed food choices.
Much more research is needed to unravel how cholesterol interacts with our genes and other chemicals in the body to increase not only cardiovascular risks, but other risks such as diabetes and dementia.
Heart UK meal ideas – heartuk.org.uk/uclp-menu-plan
Main L, Rai B – 4 Steps to Lower Cholesterol: The practical guide to a healthy heart. Vermillion, 2015
PHE NHS Health Check – gov.uk/government/news/public-health-england-publishes-latest-statistics-on-nhs-health-check
NHS Health Check implementation review and action plan, 2013 –
1. NHS Choices. High cholesterol – prevention. nhs.uk/Conditions/Cholesterol/Pages/Prevention.aspx (accessed 7 March 2016).
2. Public Health England. NHS Health Check programme: priorities for research. gov.uk/government/uploads/system/uploads/attachment_data/file/376765/20140918_NHS_Health_Check_Research_Priorities_v11.pdf (accessed 7 March 2016).
3. Public Health England. First national evaluation of NHS Health Check programme published. gov.uk/government/news/first-national-evaluation-of-nhs-health-check-programme-published (accessed 7 March 2016).
4. Public health England. Public Health England publishes latest statistics on NHS Health Check, 2013. gov.uk/government/news/public-health-england-publishes-latest-statistics-on-nhs-health-check (accessed 7 March 2016).
5. Dalton B et al. Implementation of the NHS Health Checks Programme: baseline assessment of risk factor recording in an urban culturally diverse setting. Family Practice 2010;28(1):34-40.
6. Marshall T. The use of cardiovascular risk factor information in practice databases: making the best of patient data. British Journal of General Practice 2006;56:600-605.
7. Tuse JP, Ismail HM, Ha PB, Bartolotte C. Nutritional Update for Physicians: Plant – Based Diets. The Permanente Journal 2013;17(2):61-66.
8. Doll H et al. The rise of cholesterol testing: how much is unnecessary? British Journal of General Practice 2011;61(583):e81-8.
9. Petty D et al. Can cheap generic statins achieve national cholesterol lowering targets? Journal of Health Services Research and Policy, 2008.