Cholesterol Lowering Program

Hypercholesterolemia, also called high cholesterol, is the presence of high levels of cholesterol in the blood. It is a form of hyperlipidemia, high blood lipids, and hyperlipoproteinemia (elevated levels of lipoproteins in the blood)

Cholesterol is a fatty substance that occurs naturally in the body. It performs several vital functions. It is needed to make the walls surrounding the body's cells and is the basic material that is converted to certain hormones. Your body makes all the cholesterol you need. You need only a small amount of fat in your diet to make enough cholesterol to stay healthy.

The fat and cholesterol you eat are absorbed in the intestine and transported to the liver. The liver converts fat into cholesterol, and releases cholesterol into the bloodstream. There are two main types of cholesterol: low-density lipoprotein (LDL) cholesterol (the "bad" cholesterol) and high-density lipoprotein (HDL) cholesterol (the "good" cholesterol).

High levels of LDL cholesterol are linked to atherosclerosis, which is the accumulation of cholesterol-rich fatty deposits in arteries. This can cause arteries to narrow or become blocked, slowing or stopping the flow of blood to vital organs, especially the heart and brain. Atherosclerosis affecting the heart is called coronary artery disease, and it can cause a heart attack. When atherosclerosis blocks arteries that supply blood to the brain, it can cause a stroke.

People with high levels of HDL cholesterol are less likely to develop cardiovascular disease. However, if a person has both a high HDL and high LDL cholesterol level, he or she might still need treatment to lower the LDL level.

Types

1. Primary: it is also called familial due to a genetic defect. Primary hyperlipidemia can usually be resolved into one of the abnormal lipoprotein patterns.
2. Secondary: it is acquired because it is caused by another disorder like diabetes, nephritic syndrome, chronic alcoholism, hypothyroidism and with use of drugs like corticosteroids, beta blockers and oral contraceptives. Secondary hyperlipidemia together with significant hypertriglyceridemia can cause pancreatitis.

Cause

• Unhealthy diet
• Lack of physical activity
• Smoking or exposure to tobacco smoke
• Being overweight or obese
• Diabetes mellitus
• Alcohol overuse
• Chronic kidney disease
• Hypothyroidism
• Primary biliary cirrhosis and other cholestatic liver diseases
• Drugs, such as thiazides, beta-blockers, retinoids, highly active antiretroviral agents, cyclosporine, tacrolimus, estrogen and progestins, and glucocorticoids.

Symptoms

Usually, people with hyperlipidemia do not experience any symptoms. However, those with familial, or inherited hyperlipidemia, may develop yellow, fatty growths around the eyes or joints. Most people with high cholesterol don't have any symptoms until cholesterol-related atherosclerosis causes significant narrowing of the arteries leading to their hearts or brains. The result can be heart-related chest pain (angina) or other symptoms of coronary artery disease, as well as symptoms of decreased blood supply to the brain (transient ischemic attacks or stroke). About 1 out of every 500 people has an inherited disorder called familial hypercholesterolemia, which can cause extremely high cholesterol levels (above 300 milligrams per deciliter). People with this disorder can develop nodules filled with cholesterol (xanthomas) over various tendons, especially the Achilles tendons of the lower leg. Cholesterol deposits also can occur on the eyelids, where they are called xanthelasmas.

Risk factors for coronary artery disease include

• Being a male older than 45
• Being a female older than 55
• Being a female with premature menopause
• Having a family history of premature coronary artery disease (a father or brother younger than 55 with coronary artery disease or a mother or sister younger than 65 with coronary artery disease)
• Smoking cigarettes
• Having high blood pressure
• Not having enough good cholesterol (high density lipoprotein or HDL)

The ideal cholesterol LDL level is less than 70 milligrams per deciliter. If you have coronary artery disease, peripheral arterial disease or have had a stroke from atherosclerosis, this should be your goal. However, if you do not have cardiovascular disease and no risk factors for it, an LDL cholesterol level of 100 – 130 may be acceptable. Your level of HDL cholesterol also matters. People with levels below 40 milligrams per deciliter are more likely to develop atherosclerosis, heart disease and stroke

Conventional treatment of hyperlipidemia

Lifestyle changes that can lower your cholesterol include a healthy diet, weight loss, and exercise. For some people, diet and lifestyle changes may be enough to bring their cholesterol levels into a healthy range. Other people may need medicines.

Treatment: The initial treatment of high cholesterol should always be lifestyle changes. This means altering your diet and getting more exercise. Some people respond dramatically to dietary changes.

Diet: There is no consensus on the best diet. The most effective diet to lower total and LDL cholesterol is a vegetarian diet. However, this is not an easy diet to follow.
Many people prefer a "Mediterranean style" diet. There is no strict definition for what should be included in this type of diet. In general, this means.

• Getting the majority of daily food calories from plant sources, especially fruits and vegetables, grains, beans, nuts, and seeds
• Using olive oil as the principal fat, replacing other fats and oils
• Having some low fat cheese and/or yogurt daily
• Eating fish at least a couple times per week
• Limiting processed foods
• Drinking alcohol in moderation unless medically not indicated

To maintain a desirable weight, you should take in only as many calories as you burn each day. If you need to lose weight, you need to take in fewer calories than you burn. People who aren't sure how to follow such a diet may find it useful to work with a health care professional such as a dietitian, nutritionist, doctor or nurse. In addition to dietary changes, you should get at least 30 minutes of moderate-intensity exercise, such as brisk walking, daily.

Medications: Whether you need medication to lower your cholesterol level depends on how you respond to diet and your personal risk of heart attack and stroke. There are five types of cholesterol-lowering medications. However, a statin drug should almost always be the first choice to lower LDL cholesterol. Statins are also called HMG-CoA reductase inhibitors. They include lovastatin, simvastatin, pravastatin, fluvastatin, atorvastatin (Lipitor), and rosuvastatin. Statins block an enzyme called HMG-CoA reductase, which is necessary for the production of cholesterol. Statins do much more than lower your LDL cholesterol number. They lower your risk of developing hardening of the arteries (atherosclerosis) and reduce the chance that you will have a heart attack or stroke. When a person taking a statin does not reach goal, doctors sometimes add ezetimibe. Ezetimibe inhibits absorption of cholesterol from the intestine.

The newest cholesterol lowering therapies, called PCSK9 inhibitors, are more potent than statins. PCSK9 inhibitors are most useful for people with familial hypercholesterolemia. These people have extremely high cholesterol levels. People with coronary artery disease who either don't reach goal with a high dose statin drug or cannot tolerate statins because of side effects may also be candidates for this new therapy.
PCSK9 inhibitors are much more expensive than most statins

Other drugs that can lower cholesterol include

• Bile acid-binding resins, including cholestyramine and colestipol.
• Niacin (several brand names). Niacin is also being used less often. In doses needed to reduce LDL cholesterol, side effects are common.
• Fibrates, including gemfibrozil, fenofibrate and clofibrate. Fibrates are especially helpful for people with high triglyceride levels. In addition to dietary changes or medication, people with high cholesterol should try to control their other risk factors for coronary artery disease. This means keeping blood pressure at normal levels, not smoking, controlling your blood sugar, maintaining or losing weight and following a regular exercise schedule.

Prognosis

The effectiveness of following a healthy diet and using medications to lower cholesterol varies from person to person. On average, diet and exercise can lower LDL cholesterol by about 10%. Medications can lower LDL cholesterol by another 20% to more than 50%.

The basic principles of treatment for Hyperlipidemia can be categorized in three groups:

1. Avoidance of causative factors - Heavy to digest food articles, curd intake, meat, sedentary life style, day sleep etc.
2. General principles of management, which include

• Fasting
• Elimination treatment – the therapies which help in reducing the fat and removing the undigested food particles and removing the toxins are administered like vamana, virechana rtc. And external therapies which help in relaxing the body and reducing the sub dermal fat like abhyanga, udvartana et. are advised.
• Palliative treatment – drugs which are hypolipidemic in nature and which help in regulating the metabolism are administered usually after elimination treatment.

3. Modified Diet & Life Style - bitter, pungent astringent taste, dry, hot, dried beans, whole grains etc. should be added in diet. There are several plants and herbs mentioned in Ayurveda that are reported to be beneficial for hypercholesterolemia. One of the important traditional Ayurvedic formulations for managing high cholesterol is Triphala, which is a combination of three herbal products. Avoid sweet, salt, sour, rice, wheat, sweet milk and fermented food.