Cholesterol risk: causes, risks and treatments

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Cardiovascular disease is the leading cause of death in the world. Every year there are more than 4 million deaths in Europe while in Italy it affects 230,000 people and causes 35.8% of deaths: one in 3 people dies from it. The guidelines for the prevention of cardiovascular diseases consider these pathologies as the product of various risk factors. Some are modifiable, such as overweight or obesity, sedentary lifestyle, smoking habits, alcohol abuse, while others are not, such as genetic factors, family history of cardiovascular events, age and gender, presence of pathologies such as hypertension, diabetes, dyslipidemias. We talk about it with Monica Antonini, medical director at the Endocrinology and Metabolic Diseases Complex Unit of the University Hospital of Parma.
What is meant by dyslipidemia?
«This term refers to an increase in blood values ​​of cholesterol and triglycerides or both. High cholesterol levels, in particular LDL (Low Density Lipoprotein) cholesterol, known as “bad cholesterol”, are directly correlated with increased cardiovascular risk.”
What are the causes?
«Dyslipidemias can have primary or secondary causes. The primary causes are represented by genetic mutations, single or multiple, which determine an excessive production or defective elimination of triglycerides and LDL cholesterol, or a reduced production or excessive elimination of HDL cholesterol, the so-called “good”. Among the secondary causes: sedentary lifestyle, associated with an excessive dietary intake of total calories and saturated fats, some diseases including diabetes, chronic kidney disease, primary biliary cirrhosis or hypothyroidism”.
What risks is it exposed to and what are the treatments?
«Dyslipidemia can cause vascular diseases (heart attack, stroke, peripheral arterial disease of the lower limbs) or acute pancreatitis. Some local signs of high plasma cholesterol levels are skin xanthomas or xanthelasmas, i.e. accumulations of fat on the skin or eyelids respectively. The diagnosis is made with a simple blood test. Therapy is personalized based on individual cardiovascular risk and the therapeutic goal to be achieved. To evaluate the risk we refer to Score cards which allow an estimate of the probability of fatal cardiovascular events within 10 years following the initial observation, in a patient without a history of arteriosclerotic disease. Depending on the risk assessed for each patient, we are able to determine the LDL target and set the most suitable therapy.”
At a pharmacological level, which therapy can be used?
«If pharmacological therapy is indicated, we have drugs that inhibit the hepatic production of cholesterol, such as statins, among the most used in the world, effective and safe, which can be combined with therapies that reduce the intestinal absorption of cholesterol, such as ezetimibe. In recent years, the introduction of monoclonal antibodies, administered subcutaneously on a biweekly or monthly basis, has played a key role in statin-intolerant patients and in high-risk patients who did not reach the target with conventional therapy.”
Are supplements for controlling cholesterol and triglycerides really effective?
«There are many supplements and the substances contained in the various products are different. Among the main ones: berberine, policosanols, soluble fibers (for example betaglucans), phytosterols, fermented red rice. The latter is widely used due to its richness in monacolin K, capable of lowering cholesterol levels by up to 20%. Berberine and policosanols have less marked effects, often to strengthen their effectiveness, they are found in products combined with red yeast rice or phytosterols. Omega3, on the other hand, is very effective in reducing triglyceride values. Supplements should always be prescribed under medical supervision, especially those based on red yeast rice, due to their action similar to that of statins. Although the dosage of the active ingredient is low, in some subjects it can cause the same side effects as statins, for example muscle pain.”
How much is it possible to reduce cholesterol through diet and physical activity?
«Diet accounts for approximately 20% of the total cholesterol content. Various studies, however, have shown that a lifestyle intervention significantly modifies cardiovascular risk by acting on the factors that produce it (cholesterol and triglyceride levels, blood pressure values, blood sugar), therefore it must be recommended to all patients. Physical activity also plays a key role, as does reducing body weight. Several studies have shown that the Mediterranean diet is the most effective and balanced. The reduction in the intake of saturated fatty acids, below 7% of the total energy of the diet, is one of the main aspects of the intervention, with greater attention to qualitative improvement rather than to a quantitative reduction of lipids. Not all patients with dyslipidemia are overweight or obese. In the familial forms, patients tend to be young and of normal weight, while in overweight patients dyslipidemia is often present. Visceral fat assumes particular importance, related to dyslipidemia and increased cardiovascular risk. Even small increases compared to normal have an impact, therefore the cut-offs relating to waist circumference are particularly strict in the European guidelines of scientific societies. In conclusion, “The Lower is better”: lowering LDL values ​​with all available therapies is an effective and safe strategy.”