Cholesterol Management

Cholesterol Management - What it is

Cholesterol is a fat-like substance that is either produced by the body or derived from food. It is necessary for the body to function normally and is used to build cell membranes, however, only a small amount of cholesterol in the blood is required to meet the body’s needs.

Cholesterol is carried through one’s bloodstream by special proteins called lipoproteins, which can be divided into two categories. The two types of lipoproteins are:

1) Low-density lipoprotein (LDL): LDL, or ‘bad’ cholesterol, will increase the build-up of fats in the arteries, and may cause the arteries to be clogged.

2) High-density lipoprotein (HDL): HDL, or ‘good’ cholesterol, removes cholesterol from the cells before they are deposited as plaque in the arteries, thus preventing the build-up of fats in the arteries.

The goal of good cholesterol management is to keep your total cholesterol level as low as possible, because any excess cholesterol in the blood may be deposited in the arteries, including the heart’s coronary arteries. This build-up causes the arteries to harden and narrow (atherosclerosis), thus reducing blood flow to the heart. If insufficient blood and oxygen are delivered to the heart, one may experience chest pain. If the blood supply to a portion of the heart is completely cut off by a blockage, a heart attack may occur.

Cholesterol Management - Causes and Risk Factors

There are several common causes and risk factors which can increase your cholesterol levels. These risk factors can be split into two categories: modifiable and non-modifiable risk factors.

Modifiable risk factors for high cholesterol levels include:

Physical inactivity: A lack of exercise lowers high-density lipoprotein (HDL; ‘good’) cholesterol levels, which means less low-density lipoprotein (LDL; ‘bad’) cholesterol is removed from the arteries. It also causes one to gain weight, which can lead to high cholesterol.
Obesity: Obesity is associated with lower HDL cholesterol levels, higher LDL cholesterol levels and higher triglyceride levels, which can lead to greater build-up of plaque in the arteries.
Diet: Eating foods high in saturated fat or trans fat can lead to unhealthy cholesterol levels.
Alcohol: Drinking too much alcohol raises total cholesterol level.
Smoking: Smoking can result in coronary atherosclerosis or an accumulation of fatty deposits in the heart's artery wall. It may also may lower HDL levels.
Diabetes: Diabetes lowers HDL cholesterol levels and raises LDL cholesterol levels. Maintaining a healthy weight, a balanced diet and a regular exercise routine can help regulate one’s blood glucose level, preventing the progression of diabetes mellitus.

Non-modifiable risk factors for high cholesterol levels include:

Other medical conditions: Certain health problems can increase cholesterol levels. Please speak to your doctor about your risk of high cholesterol and how you can best manage it.
Family History: Individuals with a family history of high cholesterol have a higher risk of developing high cholesterol. As such, they should have their cholesterol levels checked more often.
Age: High cholesterol can be more common in those above the age of 40. As we age, the body gradually loses its ability to remove LDL cholesterol, which leads to higher cholesterol levels.

Since high cholesterol has no symptoms, those who are above the age of 40 or have greater risks of developing high cholesterol should check their cholesterol levels regularly to reduce their susceptibility to

coronary artery disease.

Cholesterol Management - Other Information

Classifying cholesterol levels

It is important to check your cholesterol levels regularly especially if you have any risk factors. If your total cholesterol level is between 5.2 and 6.1mmol/L, you are at a higher risk for coronary artery disease. If your total cholesterol level registers at 6.2 mmol/L and above, you have hypercholesterolaemia, which is attributable to genetic factors, diabetes mellitus, obesity, and poor eating habits.

The desirable level of LDL cholesterol depends on your pre-existing risk for coronary heart disease. If you already have coronary artery disease, peripheral vascular disease, or diabetes, you are in the high-risk group and there is a stringent limit on the acceptable level of LDL cholesterol. Conversely, if you have none or only one of the risk factors, a higher value of LDL cholesterol is acceptable before medical intervention.

HDL cholesterol protects against heart disease, hence a higher HDL cholesterol level is considered better. A HDL cholesterol level that is less than 1.0 mmol/L is considered to be low and the patient is thus at risk of developing heart disease. High levels of triglyceride also put you at a greater risk of cardiovascular disease. Elevated triglyceride levels are more common in people who are obese or in those with poorly controlled diabetes. As you get older and more overweight, your triglyceride and cholesterol levels tend to increase.

Classification of Total, LDL and HDL Cholesterol and Triglyceride Levels

Total Blood Cholesterol (mmol/L [mg/dL])
< 5.2 (200)	Desirable
5.2 – 6.1 (200 – 239)	Borderline High
≥ 6.2 (240)	High
LDL Cholesterol (mmol/L [mg/dL])
< 2.6 (100)	Optimal
2.6 – 3.3 (100 – 129)	Desirable
3.4 – 4.0 (130 – 159)	Borderline high
4.1 – 4.8 (160 – 189)	High
≥ 4.9 (190)	Very High
HDL Cholesterol (mmol/L [mg/dL])
< 1.0 (40)	Low
1.0 – 1.5 (40 – 59)	Desirable
≥ 1.6 (60)	High
Triglyceride (mmol/L [mg/dL])
< 1.7 (150)	Optimal
1.7 – 2.2 (150 – 199)	Desirable
2.3 – 4.4 (200 – 399)	High
≥ 4.5 (400)	Very high

HDL=high-density lipoprotein; LDL=low-density lipoprotein

Source: MOH Clinical Practice Guidelines 2/2006

Managing high cholesterol

A combination of lifestyle changes and medication should effectively bring one’s cholesterol levels under control.

1) Lifestyle changes

Lifestyle changes are usually the first strategies for preventing high cholesterol.

Eat healthily:

Eat more foods rich in omega-3 fatty acids and fibre such as salmon and oatmeal. Reduce consumption of saturated and trans fats, which are often found in red meat, margarine and desserts.

Recommended servings for various types of food (Click to expand)

Maintain a healthy weight:

Obesity raises levels of LDL cholesterol, and the excess body fat slows down the body’s ability to remove LDL cholesterol. This combination of factors increases cholesterol levels to unhealthy levels and increases one’s risks of heart disease and stroke. One should achieve and maintain a healthy body mass index (BMI). The healthy BMI range for Asians is between 18.5 and 22.9 kg/m².

Exercise regularly:

Moderate-intensity exercise raises HDL cholesterol levels, and can help with maintaining a healthy weight. These can be simple exercises incorporated into your daily life, such as walking up the stairs instead of taking the lift.

Healthy adults should complete at least 150 minutes of moderate-intensity exercise (such as brisk walking) in a week. Please seek your doctor’s advice for physical exercises that are suitable for you.

Quit smoking:

Smoking cessation improves HDL cholesterol levels and lowers LDL cholesterol levels. Non-smokers should also avoid inhaling second-hand smoke as much as possible.

Drink alcohol in moderation:

An excessive amount of alcohol increases both triglyceride and total cholesterol levels.

2) Medication

Medications might be prescribed if one still has high cholesterol after making lifestyle modifications. Medications are prescribed in consideration of the patient’s risk factors and generally aim to:

Lower triglyceride levels
Lower LDL cholesterol levels
Increase HDL cholesterol levels

Patients should take their medication regularly according to the prescription given and let their doctor know if they experience any side effects. It is advisable not to stop medication without checking with your care team.