How Cholesterol Works

Have you ever been about to take a big bite of your triple chocolate fudge cake when
someone leaned over and said "you better watch your cholesterol"? That's happening to all
of us more frequently because medical research has shown that high levels of cholesterol
are associated with heart disease, the nation's number one killer. Statistics say that more
than half of all Americans have cholesterol levels that exceed the recommended total and
one in five Americans has cholesterol levels that are considered high.

You can check nutrition labels, like this one from a can of
tuna, for cholesterol information.

What we don't often hear is the important fact that some cholesterol is vital to human life. In
this article, we will take a look at cholesterol, both why it is needed for normal human--and
animal--functions and why at high levels and in many individuals, it can be deadly. We'll also
describe what contributes to and the treatments for high cholesterol levels so that you can
take steps to limit your health risks. But first, let's answer an important question: "What is
cholesterol?"

What is Cholesterol?
Cholesterol is a waxy, fat-like compound that belongs to a class of molecules called
steroids. It's found in many foods, in your bloodstream and in all your body's cells. If you
had a handful of cholesterol, it might feel like a soft, melted candle. Cholesterol is essential
for:

• Formation and maintenance of cell membranes (helps the cell to resist changes in
temperature and protects and insulates nerve fibers)
• Formation of sex hormones (progesterone, testosterone, estradiol, cortisol)
• Production of bile salts, which help to digest food
• Conversion into vitamin D in the skin when exposed to sunlight.

The formation of cholesterol involves a series of complicated biochemical reactions that

begin with the widespread 2-carbon molecule Acetyl CoA: Acetyl CoA (C2) --> mevalonate
(C6) --> isopentenyl pyrophosphate (C5) --> squalene (C30) --> cholesterol (C27).
Cholesterol is made primarily in your liver (about 1,000 milligrams a day), but it is also
created by cells lining the small intestine and by individual cells in the body.
 Most of the body's cholesterol is manufactured in the liver.

Blood Cholesterol vs. Dietary Cholesterol

It may surprise you to know that our bodies make all the cholesterol we need. When your
doctor takes a blood test to measure your cholesterol level, the doctor is actually measuring
the amount of circulating cholesterol in your blood, or your blood cholesterol level. About
85 percent of your blood cholesterol level is endogenous, which means it is produced by
your body. The other 15 percent or so comes from an external source -- your diet. Your
dietary cholesterol originates from meat, poultry, fish, seafood and dairy products. It's
possible for some people to eat foods high in cholesterol and still have low blood cholesterol
levels. Likewise, it's possible to eat foods low in cholesterol and have a high blood
cholesterol level.

So, why is there so much talk about cholesterol in our diet? It's because the level of
cholesterol already present in your blood can be increased by high consumption of
cholesterol and saturated fat in your diet. This increase in dietary cholesterol has been
associated with atherosclerosis, the build-up of plaques that can narrow or block blood
vessels. (Think about what happens to your kitchen drain pipes when you pour chicken fat
down the sink.) If the coronary arteries of the heart become blocked, a heart attack can
occur. The blocked artery can also develop rough edges. This can cause plaques to break
off and travel, obstructing blood vessels elsewhere in the body. A blocked blood vessel in the
brain can trigger a stroke.
 This coronary artery is becoming dangerously blocked as the
cholesterol builds up.

The average American man eats about 360 milligrams of cholesterol a day; the average
woman eats between 220 and 260 milligrams daily. So how are we doing? The American
Heart Association recommends that we limit our average daily cholesterol intake to less than
300 milligrams. Obviously, people with high levels of cholesterol in the blood should take in
even less.

Good vs. Bad Cholesterol

Comments about "good" and "bad" cholesterol refer to the type of carrier molecule that
transports the cholesterol. These carrier molecules are made of protein and are called
apoproteins. They are necessary because cholesterol and other fats (lipids) can't dissolve
in water, which also means they can't dissolve in blood. When these apoproteins are joined
with cholesterol, they form a compound called lipoproteins. The density of these
lipoproteins is determined by the amount of protein in the molecule. "Bad" cholesterol is the
low-density lipoprotein (LDL), the major cholesterol carrier in the blood. High levels of
these LDLs are associated with atherosclerosis. "Good" cholesterol is the high-density
lipoprotein (HDL); a greater level of HDL--think of this as drain cleaner you pour in the sink--
is thought to provide some protection against artery blockage.

A high level of LDL in the blood may mean that cell membranes in the liver have reduced the
number of LDL receptors due to increased amounts of cholesterol inside the cell. After a cell
has used the cholesterol for its chemical needs and doesn't need any more, it reduces its
number of LDL receptors. This enables LDL levels to accumulate in the blood. When this
happens, the LDLs begin to deposit cholesterol on artery walls, forming thick plaques. In
contrast, the HDLs--the "good" guys--act to remove this excess cholesterol and transport it to
the liver for disposal.

A third group of carrier molecules, the very low-density lipoproteins (VLDL) are converted to
LDL after delivering triglycerides to the muscles and adipose (fat) tissue.
The levels of HDL, LDL and total cholesterol are all indicators for atherosclerosis and heart
attack risk. People who have a cholesterol level of 275 or greater (200 or less is desirable)
are at significant risk for a heart attack, despite a favorable HDL level. In addition, people
who have normal cholesterol levels but low HDL levels are also at increased risk for a heart
attack.

Risk Factors
There are a number of factors that influence a person's cholesterol levels. They include diet,
age, weight, gender, genetics, diseases and lifestyle.

Diet
There are two dietary factors associated with increases in blood cholesterol levels:

• Eating foods that are high in saturated fats, even if the fats themselves do not
contain cholesterol. (These include foods containing high levels of hydrogenated
vegetable oils, especially palm and coconut oils, avocados and other high-fat foods
of vegetable origin.)
• Eating foods containing high levels of cholesterol. (This group includes eggs and red
meat--the most maligned of the cholesterol culprits--as well as lard and shrimp.
These foods can significantly raise blood cholesterol levels, especially when
combined with foods that are high in saturated fat.)

It's important to note that only foods of animal origin contain cholesterol. Lack of awareness
of this fact has led to some confusing labels at the grocery store. For example, some items
that are high in saturated fats from plant sources bear labels claiming that they are 100
percent cholesterol free. The statement may be true, but it's generally misleading because it
implies that the product is definitely beneficial to your health.

Age
The blood levels of cholesterol tend to increase as we age--a factor doctors consider when
deciding treatment options for patients with certain cholesterol levels.

Weight
People who are overweight are more likely to have high blood cholesterol levels. They also
tend to have lower HDL levels. The location of the excess weight also seems to play a role in
cholesterol levels. A greater risk of increased cholesterol levels occurs when that extra
weight is centered in the abdominal region, as opposed to the legs or buttocks.

Gender
Men tend to have higher LDL levels and lower HDL levels than do women, especially before
age 50. After age 50, when women are in their post-menopausal years, decreasing amounts
of estrogen are thought to cause the LDL level to rise.

Genetics
Some people are genetically predisposed to having high levels of cholesterol. A variety of
minor genetic defects can lead to excessive production of LDLs or a decreased capacity for
their removal. This tendency towards high cholesterol levels is often passed on from parents
to their children. If your parents have high cholesterol, you need to be tested to see if your
cholesterol levels are also elevated.
Diseases
Diseases such as diabetes can lower HDL levels, increase triglycerides and accelerate the
development of atherosclerosis. High blood pressure, or hypertension, can also hasten the
development of atherosclerosis, and some medications used to treat it can increase LDL and
triglycerides and decrease HDL levels.

Lifestyle
Factors that negatively affect cholesterol levels also include high levels of stress, which can
raise total cholesterol levels, and cigarette smoking, which can lower a person's HDL level as
much as 15 percent. On the other hand, strenuous exercise can increase HDL levels and
decrease LDL levels. Exercise also can help reduce body weight, which, in turn, can help
reduce cholesterol. Recent research has shown that moderate alcohol use (one drink per
day for women, two drinks a day for men) can raise HDL cholesterol and therefore reduce
the risk of heart attack. Despite such research, it is difficult to recommend the habitual use of
alcohol, because there are also negative health consequences associated with alcohol use
and a high potential for abuse.

Always remember that risk factors for high cholesterol and cardiovascular disease don't exist
in a vacuum--they tend to amplify each other. Reducing the risk of a cardiovascular disease
involves eliminating all of the risk factors that we can control and seeking medical advise for
those we can't.

Testing and Prevention

How often should I have my cholesterol levels tested?
You should get your cholesterol tested every three to five years, more often if you have high
cholesterol levels. Please refer to the table below for guidelines for total cholesterol, LDL and
HDL levels.

Desirable Borderline Undesirable

Total Cholesterol Below 200 200-240 Above 240
HDL Cholesterol Above 45 35-45 Below 35
LDL Cholesterol Below 130 130-160 Above 160
Total Cholesterol/HDL Below 4.5 4.5-5.5 Above 5.5
LDL/HDL Below 3 3-5 Above 5
Figure 1 - Blood Type Relationships

What can I do to reduce my cholesterol?

There are several steps you can take to reduce your cholesterol levels. The first is to eat a
low-fat, low-cholesterol diet. That means keeping your total fat consumption--saturated,
polyunsaturated and monounsaturated--to fewer than 30 percent of your daily intake of
calories. (See How Fat Works for details.) Remember to keep your cholesterol intake to
fewer than 300 milligrams per day. Saturated fats contained in butter, whole milk,
hydrogenated oils, chocolate shortening, etc. should comprise no more than one third of your
total fat consumption. To reduce your total fat and cholesterol intake, limit your consumption
of meats such as beef, pork, liver and tongue (always trim away excess fat). In addition,
avoid cheese, fried foods, nuts and cream, and try to curb your intake of eggs to no more
than four per week. Try to eat meatless meals several times a week, use skim milk and
include fish in your diet. Eat a wide variety of vegetables, pasta, grains and fruit. Another
good tip is to look at the package label of the foods you buy, and restrict your choices to
foods containing 3 grams of fat or less per serving.

There is evidence that water-soluble fibers can aid in lowering cholesterol; these foods
include the fiber in oat or corn bran, beans and legumes, pectin found in apples and other
fruits, and guar that is used as a thickener. Although highly touted by the media and health
food stores, the phospholipid Lecithin has not been confirmed as a reducer of blood
cholesterol levels.

If you are overweight, trying to lose weight and including aerobic exercise in your routine can
help raise those desirable HDL levels. Diet and exercise alone can decrease cholesterol
levels by up to 15 percent.

It probably comes as no surprise to you that, if you smoke, you should quit to avoid a wide
range of health problems, including lower HDL levels and increased risk of heart attack.

Medicating High Cholesterol

Sometimes positive changes in diet, lifestyle and exercise are not enough. In these cases,
doctors may consider the use of medication that lowers cholesterol. The decision to have a
patient begin medication is often based on high levels of LDL cholesterol and other risk
factors for cardiovascular disease. For example, medication may be indicated if your LDL
level is over 190 or is over 160 and you have several other risk factors for cardiovascular
disease.

Drugs that reduce LDL blood levels can prevent or reduce the build-up of artery blocking
plaques and can limit the possibility of the release of those plaques as dangerous blood
clots. There are several types of drugs that can help reduce blood cholesterol levels. The
most commonly prescribed are the statins, HMG-CoA reductase inhibitors, including:

• Lovastatin (Mevacor)
• Simvastatin (Zocor)
• Atorvastatin (Lipitor), a new, highly potent drug

These drugs work within the liver to directly prevent the formation of cholesterol and can
lower LDL cholesterol by as much as 40 percent. Research also shows that these drugs can
reduce the risk of death from cardiovascular disease. Another major drug category is the
resins, which bind bile acids, causing the liver to produce more of them and using up
cholesterol in the process. By "tying" it up, these drugs make cholesterol less available in the
blood. They include:

• Cholestyramine (Questran)
• Colestipol (Colestid)

The B vitamin Niacin, in high doses, can lower triglycerides and LDL levels and increase
HDL levels. Niacin has been proven to reduce a person's risk of having a second heart
attack. Last are the drugs in the fibrates category, which lower triglycerides and can
increase HDL levels. These include:

• Gemfibrozil (Lopid)
• Fenofibrate (Tricor)
The decision to take cholesterol- or lipid-lowering drugs is not taken lightly by your doctor.
These drugs can be fairly expensive and are often required for many years or even the rest
of your life. It is also important to note that some of these drugs can have dangerous side
effects, such as damage to the liver.

Adopting a healthy lifestyle and visiting your doctor regularly can help curb your risks of
problem cholesterol. Have your cholesterol levels checked by a physician, rather than risk
incorrectly interpreting numbers in self test kits currently on the market. Remember,
cholesterol is necessary for life but it can also be very harmful and requires monitoring. So,
watch your cholesterol and keep in mind that, for every 1 percent drop in your cholesterol
level, your risk of heart attack is lowered by 2 percent.