An Overview of Hypercholesterolemia

The Risks Associated with High Cholesterol

Running and other aerobic exercise leading to weight loss can lower high cholesterol levels in hypercholesterolemia
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In This Article

More than 34 million Americans have an excess amount of cholesterol in the bloodstream, a condition known as hypercholesterolemia. Though they may be symptom-free and unaware of this abnormality, it may lead to long-term health consequences, including an increased risk of heart attack and stroke. What are the causes, diagnosis, and treatments of hypercholesterolemia? Discover how high cholesterol levels may be managed with diet, exercise, and medications to avoid potentially fatal consequences.

Definitions

Cholesterol is a natural fat-like substance, waxy in appearance, that is either produced in the body or obtained from foods that come from animals. Dietary sources of cholesterol include:

  • Egg yolks
  • Meat
  • Poultry
  • Fish
  • Dairy products

Cholesterol is a normal and necessary part of the body. It is used to build cell membranes, make hormones, and aid fat digestion. Too much of it can be a problem, however. When excessive levels are present, there is an increased risk of heart disease and stroke.

Hypercholesterolemia is defined as high levels of cholesterol as measured in the blood. It is also known as hyperlipidemia (lipids are a name for fatty acids in the body) and dyslipidemia (indicating abnormal lipid levels).

Hypertriglyceridemia specifically refers to elevated levels of triglycerides, the main constituent of natural fats and oils, and this may contribute to overall high levels of cholesterol.

Symptoms

There are no specific symptoms associated with hypercholesterolemia. It is typically detected based on a blood test. Nevertheless, there may be signs of high cholesterol levels in the body.

Inherited, or familial, hypercholesterolemia may lead to very high levels of cholesterol within the body. This cholesterol may accumulate in some unusual places. It may build up within tendons (called tendon xanthomas), affecting the Achilles tendon, hands, and fingers. It may also collect under the skin of the eyelids (called xanthelasmata). Finally, it may discolor the edges of the cornea, creating a gray-colored ring around the colored iris within the eye (called arcus cornealis or arcus senilis).

Causes

There are several broad categories of causes of hypercholesterolemia: genetics, lifestyle, and associated health conditions. These risk factors may vary based on age, gender, and other considerations.

Genetics

Unfortunately, some people have a genetic predisposition that can increase the likelihood of developing hypercholesterolemia. As such, they may have elevated cholesterol levels at a younger age, sometimes even in childhood.

The most common genetic mutations that increase cholesterol levels include:

  • APOB
  • LDLR
  • LDLRAP1
  • PCK9

Most people with a genetic predisposition towards familial hypercholesterolemia have a mutation affecting the LDLR gene. This gene normally creates the low-density lipoprotein receptor. Found on the surface of cells, it binds low-density lipoproteins (LDLs). LDLs are the primary carriers of cholesterol within the blood, and normal binding carries the cholesterol into cells so it can be degraded. Without properly functioning receptors, ever-higher levels of cholesterol circulate within the blood.

Genetic forms of hypercholesterolemia are believed to occur less frequently. It may affect 1 in 500 people, and is more common among Afrikaners in South Africa, French Canadians, Lebanese, and Finns.

Lifestyle Factors

Beyond genetics, lifestyle plays a role in whether someone is likely to have high cholesterol levels in the blood. These are the risk factors that can be more easily changed, and include:

  • Diet: A high-fat diet with increased intake of animal protein and too little consumption of fiber from whole grains, fruits, and vegetables may contribute.
  • Exercise: A sedentary lifestyle with lack of exercise may lead to weight gain and raise cholesterol levels.
  • Tobacco smoking: Smoking cigarettes, cigars, or pipes may lower high-density lipoprotein (HDL) levels and negatively affect cholesterol levels overall.
  • Excess alcohol consumption: Drinking too much alcohol may raise triglyceride levels and increase total cholesterol overall. Men are recommended to drink two or fewer alcoholic beverages daily and women should drink no more than one, according to the National Institute on Alcohol Abuse and Alcoholism.

Health Conditions

Additional coexisting health conditions may impact the risk of having hypercholesterolemia. These conditions include:

Certain medications may also play a role, such as birth control pills, diuretics, beta-blockers, and even some antidepressants. The potential contributions from prescription medications can be reviewed with a pharmacist or primary care provider.

Diagnosis

Hypercholesterolemia is diagnosed with a blood test done at a medical laboratory in which the levels of total cholesterol and the sub-types can be identified. If the total cholesterol level exceeds 240 mg/dL, hypercholesterolemia is diagnosed.

Current guidelines recommend that these numbers be interpreted in the context of overall health. A high number does not necessarily require treatment, and interventions may vary depending on other risk factors.

Consider these ranges as rough guidelines for the interpretation of typical blood tests done to evaluate cholesterol levels:

  • Total cholesterol: calculated by adding HDL, LDL, and 20 percent of the triglyceride level. General target is less than 200 mg/dL (lower is better).
  • High-density lipoprotein (HDL): known as good cholesterol. General target is greater than 50 mg/dL (higher is better).
  • Low-density lipoprotein (LDL): known as bad cholesterol. General target is 70 to 130 mg/dL (lower is better). It is believed that everyone, regardless of health, benefits when it is less than 160 to 190 mg/dL.
  • Triglycerides: levels vary based on both age and sex. General target is 10 to 150 mg/dL (lower is better).

Remember that normal ranges may be less important than your individual cardiovascular risk, and this interpretation should be done with the help of your physician.

Treatment

It may sometimes feel like cholesterol levels are beyond your control, leaving you feeling helpless. What can be done if your cholesterol levels are too high? Fortunately, treatment options can be effective and include lifestyle changes as well as prescription medications.

Lifestyle Changes

It is always advisable to optimize body weight and eat a healthy diet, and these changes may help to lower cholesterol levels when they are too high.

Diet: Consider adopting a low-fat diet, reducing the intake of animal protein and eating more whole grains, fruits, and vegetables. Avoiding foods with high levels of saturated fat is helpful. Try to target the intake of saturated fat to be less than 30 percent of your daily calories. Consume 10 to 20 grams of soluble fiber daily, from the following sources:

  • Apples
  • Beans
  • Carrots
  • Citrus fruits
  • Oats
  • Peas

Consider reducing alcohol intake, if excessive, as this may also be helpful.

Weight Loss: If you are overweight or obese, weight loss may help to lower cholesterol levels. Try to maintain a healthy body weight by targeting a normal body mass index (BMI) or even an ideal body weight. Consider working with a nutritionist or participate in a structured weight loss program. Weigh yourself daily, avoid eating out, reduce the consumption of processed foods, cut portion sizes, and aim for gradual weight loss for sustained benefits.

Exercise: Increase your physical activity levels. Regular exercise, targeting at least 30 to 60 minutes of physical activity daily, may help to resolve hypercholesterolemia. If possible, incorporate aerobic exercise such as walking, biking, or swimming into your daily life. Reduce sedentary time, cutting out screen time and avoiding prolonged periods of sitting.

Quit Smoking: If you smoke, consider quitting as a means to reduce your cholesterol levels.

Medications

When lifestyle changes are not enough to lower cholesterol levels, it may become necessary to consider the use of medications. This determination is not one to make alone; enroll the help of a primary care provider who will evaluate risk factors such as age and overall health and minimize the potential risk for side effects.

The following classes of prescription medications are used to treat hypercholesterolemia:

Statins: These drugs block a substance the liver needs to make cholesterol, causing the liver to remove cholesterol from the blood. Statins may also help to resorb cholesterol that had previously built up in deposits lining artery walls. The statin medications include:

Bile-acid-binding resins: The liver uses cholesterol to make bile acids (a substance needed for digestion), and removal of bile acids increases their required production. By binding to bile acids, cholesterol levels are indirectly lowered as the reserves are used up. Bile acid binders include:

Cholesterol absorption inhibitors: These drugs block cholesterol absorption from the small intestine, so that cholesterol present in the diet is passed through. They may be used in combination with statins, and include:

Combination drug: There is a combination medication that both decreases absorption of cholesterol and affects liver production. This drug is:

Injectable medication: When cholesterol levels (specifically LDL levels) remain high after a heart attack or stroke, injections may be employed to help the liver absorb more LDL cholesterol, removing the amount of cholesterol circulating in the blood. These medications may also more often be used for familial hypercholesterolemia. These PCSK9 inhibitor injectable drugs, used at home one or two times per month, include:

  • Praluent (alirocumab)
  • Repatha (evolocumab)

Certain medications may be prescribed to reduce triglyceride levels when they remain elevated in isolation. Fibrates may reduce the liver’s production of very-low-density lipoprotein (VLDL) cholesterol and speed up the removal of triglycerides. Fibrates include:

  • Tricor (fenofibrate)
  • Lopid (gemfibrozil)

In addition, Niaspan (niacin) may decrease triglyceride levels by reducing the liver’s ability to produce both LDL and VLDL cholesterol. It may not help more than the use of statins alone, and because of the association with possible liver damage and stroke, it is only recommended if someone cannot tolerate taking a statin.

Finally, omega-3 fatty acid supplements may lower triglyceride levels. As these may interact with other medications, the use of omega-3 supplements should be discussed with a physician.

Medication side effects vary depending on the drug used. The ones most commonly associated with statins include muscle pains, some of which lead to the discontinuation of the medication. Stomach pain, nausea, diarrhea, and constipation may also occur with cholesterol-lowering medications. It is routinely necessary to periodically monitor liver function tests with the use of these medications.

Consequences

The long-term risks associated with hypercholesterolemia can be serious. Cardiovascular disease is the most important, and this condition is a leading cause of death. Heart attacks and strokes, both major contributors to serious impairment and fatalities, occur more often when cholesterol levels are uncontrolled. Why is this so?

High cholesterol levels lead to deposits in the walls of blood vessels. In particular, arteries that supply the heart and brain may be susceptible. As these vessels narrow with hardened plaques, the arteries may become blocked, restricting flow like a clogged pipe and damaging the tissues that depend on that blood supply. This condition, called atherosclerosis, may lead to symptoms of angina (chest pain) and coronary artery disease. It can also contribute to the risks for an aortic aneurysm and peripheral artery disease.

A Word From Verywell

If you are concerned about your risk of having hypercholesterolemia, start by speaking with your primary care provider. A simple blood test, interpreted in the context of your overall health, may help to understand your particular risks. Fortunately, changes in diet and physical activity that lead to sustained weight loss may put you on a course to avoid the long-term consequences of untreated elevated cholesterol levels. If your cholesterol levels remain elevated, prescription medications may have a role to correct the abnormality. Make an informed decision with the help of your physician and you can better your health.

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