Cholesterol – that waxy substance that is a type of blood fat or lipid – is mostly made by our own bodies and the rest, we get from food. Our tissues, skin, and hormones all benefit from cholesterol which gets around the body, attached to proteins. Trouble arises, however, when low-density lipoprotein (LDL) cholesterol is too high or there are non-optimal levels of high-density lipoprotein cholesterol (HDL), becoming a precursor to heart attacks and stroke. Globally, raised cholesterol affects 39 per cent of adults. Heart disease risk from lipids also includes another kind called triglycerides which can cause atherosclerosis leading to narrowed and hardened arteries.
The Position Paper “Improving Prevention and Control of Raised Cholesterol – A Call to Action” is a tool produced by the World Heart Federation as part of its mission to promote cardiovascular health. As a one-stop resource, it explains the scope of the problem, presents recommendations, showcases good practice and shares patient testimonials. Such a comprehensive approach is critical for addressing patients, policy-makers, medical practitioners and anyone wanting to take the best care of their heart through cholesterol awareness, monitoring and treatment.
Risks, opportunities and heredity
Lifestyle or “behavioural risk factors” can lead to unhealthy cholesterol levels. These include our food and drink habits, lack of physical activity, and smoking. High saturated fats and trans-fats as well as excess sugar and starch intake all add to the risk of unhealthy cholesterol levels. Regular physical activity is known to reduce non-HDL cholesterol levels while being inactive or leading a sedentary lifestyle can have the opposite effect. Tobacco damages the walls of the blood vessels, making them more likely to accumulate fatty deposits. In fact, smokers can have as high as a quadrupled risk of heart disease compared to non-smokers and quitting typically leads to an increase in HDL cholesterol levels.
Risk factors are compounded in those living with other conditions such as obesity, diabetes or an inherited mutated gene that causes high cholesterol. Obesity is marked by high triglycerides, lowered HDL cholesterol and normal or slightly increased non-HDL cholesterol. High blood sugar in diabetes is associated with higher levels of very low-density lipoprotein and lower HDL cholesterol which can also directly damage the lining of the blood vessels.
For 34 million people worldwide, a genetic disorder causing high cholesterol is also a challenge. Affecting all races and ethnicities, Familial Hypercholesterolemia (FH) leads to early heart attacks and heart disease. The personal accounts by patients in Hungary, the Philippines, Chile and Lebanon, emphasises the importance of early diagnosis to save lives.
FH results from one or more mutated genes, and parents with FH have a 50 per cent chance of passing on the gene. Sadly, only 10 per cent of patients know of their condition or are adequately treated. With such low general awareness, family screening is imperative.
Joining hands and hearts in the fight – “OPERATE”
We can achieve much by harnessing the lessons and knowledge across sectors and disciplines. A framework for change, OPERATE (based on infOrming, Preventing, dEtecting, tReATing and, mEasuring), sums up key recommendations for awareness campaigns, strong health policies, screening programmes and adherence to treatment plans.
Campaigns to inform the public and health professionals should urge screening and provide balanced information on the safety and efficacy of cholesterol treatment. Mobile health (mhealth) and telemedicine are increasingly useful tools for appointment reminders and text alerts. Survey results of the ‘Counter Cholesterol’ information and awareness campaign in the U.S showed the effectiveness of specific, targeted materials encouraging women to consult a health care provider about cholesterol. An online survey of approximately 1,000 women aged 25-55 years showed that infographics and videos added to the compelling nature of the messages.
Public health policies can help prevent these eight risk factors for heart disease which account for 61 per cent of cardiovascular deaths: high blood pressure or hypertension, high cholesterol, tobacco, high blood sugar, low fruit and vegetable intake, lack of physical activity, high body mass index, and alcohol. In Denmark, legislation has banned trans-fat in foods, proving effective in reducing overall intake of trans-fat including among high-risk groups in low-income populations. Data has pointed to a dropping rate of heart disease after the ban, over a period of time.
In order to detect heart disease and FH, WHF urges simplified national guidelines for screening. Methods include inexpensive and easy-to-use technologies such as cholesterol test strips and universal child-parent screening for cases of FH. One example of expansive screening is Slovenia’s nationwide programme that tests school-aged and pre-school children, with family members also being tested as may be warranted by the results. According to the Slovenian Heart Foundation, the programme has significantly increased diagnosed FH patients from 1 per cent to around 20 per cent in the last 15 years. A strong network of primary care paediatricians and a health insurance system that provides almost universal coverage have been cited as key contributing factors to the programme’s success.
Statins to treat cholesterol are included in the WHO List of Essential Medicines but their availability and affordability remain a hurdle in certain settings. Up to half of patients discontinue statin treatment within one year, making encouragement to adherence a critical part of patient care. WHF strongly supports some key steps: include ongoing education for general practitioners, greater clarification on statin regimens, free or subsidized drug provision, and eliminating duties and taxes on medicines and non-statin therapies. In the Dutch Medication Monitoring and Optimization (MeMO) programme, pharmacists refer to systemized medication history to ensure that patients are informed about many aspects of their treatment. In this way, pharmacists are also able to play a role in providing information on medication, highlighting lifestyle factors, and suggesting complementary health support.
Steady monitoring is necessary in order to measure progress and adjust as needed. WHF strongly supports collection of epidemiological data as a solid basis for assessing risks of cardiovascular disease. As an example, Turkey has been building a registry for FH to assess gaps, gain a better understanding of FH in Turkish patients and guide national policy for its diagnosis and treatment. A trainee program is helping to ensure that primary care physicians are attuned to cardiovascular risk factors and care that include FH screening and diagnosis.
Grounded in evidence and with global relevance while mindful of possible regional or national contexts, The WHF Position Paper reinforces recommendations included in 2017 WHF Cholesterol Roadmap and in the 2018 Global Call to Action on Familial Hypercholesterolemia. It is a key resource towards “reducing by one-third premature mortality from non-communicable diseases through prevention and treatment and promoting mental health and well-being by 2030,” providing data, examples, and personal stories to drive needed change.