Cholesterol: friend, foe or just a neighbor? What everyone needs to know

CrimeaPRESS reports:

Imagine a city in which everything is arranged according to the principle of circulation: roads, communications, factories and residential areas — everything is interconnected. Cholesterol works in much the same way in our body: it is not just a “bad guy”, as it is often portrayed, but an important participant in vital processes. But when there is too much of it — or when the “traffic” through the vessels is disrupted — problems begin. Today we’ll talk about what cholesterol really is, why it is needed, when you should be wary, and how to keep it under control without panic and without unnecessary drama.

Modern medicine offers several approaches to correcting cholesterol levels — from lifestyle changes to medications. Among the latter, for example, there are drugs of different classes: statins, cholesterol absorption inhibitors (ezetimibe), PCSK9 inhibitors and binding resins, which include, for example, Cholestyramine. In addition, there are supplements (for example, plant sterols, omega-3, red yeast rice — although the latter requires caution due to its unstable composition), as well as everyday “superfoods” that can have a gentle but noticeable effect on the lipid profile: oatmeal, flax, avocado, beans, garlic, berries and nuts. Below we will tell you about everything in order — from the basics to practical solutions.

What is cholesterol? And why is he not an enemy, but just… a builder

Cholesterol is a fat-like substance that is 80% produced by the body itself (mainly by the liver), and only about 20% comes from food. It’s often called «fat,» but technically it’s a steroidal alcohol. It is important to understand: without cholesterol we would not exist. He is involved in:

• the formation of cell membranes (each cell in the body is “wrapped” in a lipid double membrane, where cholesterol acts as a sealant and permeability regulator);
• synthesis of hormones (including cortisol, estrogen, testosterone, vitamin D);
• production of bile acids, without which it is impossible to absorb fats and fat-soluble vitamins (A, D, E, K);
• functioning of the nervous system — the sheaths of nerve fibers (myelin) also contain cholesterol.

That is, cholesterol is not a “slag”, but a building material. The problem arises when its transportation throughout the body is disrupted. After all, cholesterol itself does not dissolve in the blood — it needs “carrier machines”. They are called lipoproteins.

Main “types of transport”:

• LDL (low-density lipoprotein) is often called “bad” cholesterol because, when in excess, it can “get stuck” in the walls of blood vessels and participate in the formation of atherosclerotic plaques.
• HDL (high-density lipoprotein) is the “good” cholesterol: it collects excess cholesterol from tissues and returns it to the liver for disposal.
• Triglycerides are also fats, but not cholesterol. However, their levels often correlate with dyslipidemia and metabolic disorders.

Important: it is not cholesterol itself that is harmful, but an imbalance in its transport. And it is this imbalance that is worth paying attention to.

When should you sound the alarm? Symptoms — and their absence

The main insidiousness of high cholesterol is its “quiet” course. It does not hurt, does not itch, and does not manifest itself directly. There are no “signs of high cholesterol” in its pure form. Sometimes there may be:

• xanthelasmas — yellow spots under the skin of the eyelids (accumulations of cholesterol in the tissues);
• xanthomas — nodules on tendons (for example, on the Achilles);
• lipoid arc of the cornea — a whitish rim around the pupil (more often in older people, but in young people — an alarming signal).

However, most often a person learns about the problem only after:

• blood tests (lipidograms),
• or, worse, after a cardiovascular event: heart attack, stroke, angina, intermittent claudication.

When is it really worth getting checked?

• At the age of 20 years, the first lipid profile is taken to assess the baseline level.
• Further — every 4-6 years, if the indicators are normal and there are no risk factors.
• Annually or more often if:
  • there is a family history of premature cardiovascular diseases (up to 55 years in men, up to 65 years in women);
  • IHD, stroke, diabetes mellitus, hypertension have already been diagnosed;
  • there are signs of metabolic syndrome (waist circumference >94 cm in men/>80 cm in women, elevated blood pressure, high triglycerides, low HDL, insulin resistance);
  • you smoke, lead a sedentary lifestyle, often eat trans fats and refined carbohydrates;
  • you suffer from obesity (especially abdominal obesity — fat on the stomach).

Important: Even with “normal” total cholesterol numbers, there may be a hidden threat — if the LDL/HDL ratio is unfavorable, or if small, dense LDL particles are present (they are more atherogenic). Modern laboratories can evaluate this too — the so-called extended lipid profile (includes apolipoprotein B, Lp(a), LDL particle size, etc.).

illustration source: fool.com

How cholesterol is measured: from simple analysis to “advanced” diagnostics

Standard lipid profile (prescribed in the clinic)

It includes:

• total cholesterol;
• LDL (calculated using the Friedwald formula or measured directly);
• HDL;
• triglycerides.

It is given on an empty stomach (10-12 hours without food, you can have water). It is recommended not to drink alcohol or overeat fatty foods 2-3 days before the test.

Advanced lipid profile (often in private laboratories)

May include:

• LP(a) is a genetically determined risk factor, independent of other indicators;
• apolipoprotein B (ApoB) — reflects the number of atherogenic particles (in many people more accurately than LDL);
• apolipoprotein A1 (ApoA1) is a marker of “good” cholesterol;
• the ApoB/ApoA1 ratio is more prognostically significant than regular LDL/HDL;
• LDL subfractions — large (less dangerous) vs small, dense (high-risk).

Additional «related» markers

• High sensitivity C-reactive protein (hs-CRP) is an indicator of chronic inflammation, which “turns on” atherosclerosis;
• homocysteine ​​- when elevated, damages the vascular endothelium;
• glycated hemoglobin (HbA1c) — to assess glycemic control associated with dyslipidemia.

Advice: Don’t just focus on “total cholesterol.” In modern cardiology, the emphasis is on LDL levels and individual cardiovascular risk. For example, for a person with coronary heart disease, the target LDL level is less than 1.8 mmol/L, and for a healthy young person — up to 3.0 mmol/L. Goals are selected individually.

Why high cholesterol is dangerous: not only the heart, but also the brain, legs, eyes

Elevated LDL levels are the main “builder” of atherosclerotic plaques. A plaque is not just a “fat plug”, but a complex structure:

1. Damage to the endothelium (the inner lining of the vessel) — due to smoking, hypertension, high sugar, inflammation.
2. Penetration of LDL into the vessel wall → their oxidation.
3. “Call for help” of immune cells (macrophages), which “absorb” oxidized LDL and turn into “foam cells”.
4. The formation of a fibrous “lid” over the fatty core is how the plaque grows.
5. Under certain conditions (inflammation, stress, pressure surge), the plaque can open — and then a blood clot quickly forms on top of it. This is what causes:

• myocardial infarction (if a blood clot is in the coronary artery),
• ischemic stroke (if in a cerebral vessel),
• ischemia of the intestines, kidneys, limbs.

In addition, chronic hypercholesterolemia is associated with:

• liver diseases (non-alcoholic fatty liver disease — NAFLD);
• decreased cognitive function in old age (cerebral atherosclerosis);
• erectile dysfunction (impaired blood flow in small vessels);
• deterioration of vision (atherosclerosis of the central retinal artery).

But let us repeat: it is not cholesterol itself that is to blame, but its improper circulation. Even with high LDL, the risk remains low unless there is inflammation, hypertension, insulin resistance, or smoking.

illustration: stocksnap.io

What increases cholesterol: myths and reality

Statement: «Eggs = cholesterol = enemy»

Reality: For most people (70-80%), dietary cholesterol (from eggs, seafood, liver) has little effect on LDL levels. The main “culprits” for problems with blood vessels and the increase in “bad cholesterol” are saturated fats, which are rich in both eggs and other animal products; trans fats (margarine, baked goods, fast food) and refined carbohydrates (white bread, sugar, sweet drinks), which increase triglycerides and reduce HDL. The “hell mixture” here is eggs, bread and bacon, fried in butter, for breakfast.

Statement: “All fats are bad”

Reality: Monounsaturated (olive oil, avocado, nuts) and Omega-3 (flaxseed, chia, fatty fish) — reduce LDL and inflammation (provided the Omega-6/Omega-3 balance is maintained! It is better to give preference to whole foods, in which the oils are “hardwired into the matrix”, rather than processed “naked” oils in liquid form). Saturated fats (palm oil, coconut oil, full-fat dairy products, meat) are responsible for raising LDL in a significant proportion of people.

Factors that clearly increase risk:

• trans fats — even in small doses (0.5-2% of calories) increase LDL by 10-20% and reduce HDL;
• excess sugar — especially fructose (in sweet drinks): increases triglycerides, reduces HDL, stimulates LDL synthesis in the liver;
• inactivity — physical activity increases HDL and accelerates the elimination of cholesterol;
• smoking — damages the endothelium and oxidizes LDL, making it more “sticky”;
• stress and lack of sleep increase cortisol, which can disrupt lipid metabolism.

How to Control Cholesterol: 4 Levels of Protection

Level 1. Lifestyle is the first and most powerful line of defense

Nutrition (not a “diet”, but a style)
Focus on whole plant foods:

• fiber — especially soluble: oatmeal, barley, beans, apples, citrus fruits, flax. 5-10 g of soluble fiber per day reduces LDL cholesterol by 5-10%.
• phytosterols — in avocados, nuts, seeds, fortified foods (2 g per day — -8-10% LDL).
• polyphenols — in dark grapes, berries, cocoa, green tea: reduce LDL oxidation.
• Omega-3 — flax, chia, walnuts, algae; fatty fish 2 times a week — for the rest.

Avoid: trans fats (read labels: “partially hydrogenated oils” = no), sugary drinks, refined carbohydrates.

Physical activity

• Aerobic exercise (fast walking, swimming, cycling) — 150 min/week of moderate intensity;
• Strength training — 2 times a week: increases muscle mass, which improves insulin sensitivity and lipid metabolism.

Sleep and stress management
7-9 hours of sleep, mindfulness practices (meditation, breathing), walks in nature — all this affects hormonal levels and inflammation.

Quitting smoking
Already 3 weeks after withdrawal, endothelial function improves and oxidative stress decreases.

Level 2: Supplements and Nutraceuticals (as discussed with your physician)

• Plant sterols/stanols — 2 g/day (in fortified yogurts, juices or capsules) — -8-10% LDL. Safe, but not a replacement for statins at high risk.
• Omega-3 (EPA + DHA) — 1-4 g/day: reduces triglycerides, especially at levels >2.3 mmol/L.
• Red yeast rice — contains monacolin K (a natural statin), but the dosage is unpredictable, side effects like statins are possible. Not recommended without medical supervision.
• Artichoke extract, berberine, green tea extract — moderate effect, data is ambiguous, but safe.

Level 3. Drug therapy

Prescribed for:

• already suffered cardiovascular events,
• very high LDL (>4.9 mmol/l),
• high 10-year risk (according to the SCORE2, ASCVD, etc. scales).

Main groups:

• statins (atorvastatin, rosuvastatin, etc.) — “gold standard”. They reduce LDL by 30-60%, stabilize plaques, and reduce inflammation. At the same time, they have many side effects.
• Ezetimibe — blocks the absorption of cholesterol in the intestine; effect ~15-20%, often combined with statins.
• PCSK9 inhibitors (alirocumab, evolocumab) — monoclonal antibodies that reduce LDL cholesterol by up to 60%, prescribed for familial hypercholesterolemia or intolerance to statins.
• Binding resins — already mentioned above Cholestyramine. They work in the intestines: they bind bile acids, due to which the liver is forced to use cholesterol for their synthesis. The effect is moderate (-15-25% LDL), but can cause constipation and interfere with the absorption of fat-soluble vitamins and other medications (taken at 4-hour intervals).
• Bempedoic acid — a new drug that works in the liver, but does not cause myalgia (unlike statins).

Level 4. Monitoring and adaptation

• 4-12 weeks after the start of therapy — control of the lipid profile.
• Then — once every 3-12 months (depending on stability).
• Monitoring liver function tests (ALT, AST) and CPK when taking statins (rare, but important).
• An assessment of tolerability and adherence to treatment is mandatory.

“Superfoods” for the heart: what really works in everyday life

Here are the foods on which you need to build your diet:

Important: the effect is cumulative. Results are noticeable after 4-12 weeks of regular use.

Cholesterol is not an enemy, but a signal

Cholesterol is not a death sentence, but one of the indicators of metabolic health. Its level reflects how balanced your diet, activity, sleep, stress and genetics are. The main thing is not to chase the “lowest numbers”, but to strive for a stable, individual balance.

Get checked regularly. Listen to your body. Eat a variety of foods. Move. And remember: even small, but constant steps — for example, replacing white bread with whole grain bread, or taking a walk after dinner — have a greater effect over time than short-term drastic measures.

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