On a mid-September afternoon in 2021, a sudden piercing bolt of chest pain knocked 45-year-old Vincent Jerome unconscious outside his local church in Kochi, Kerala. Locals rushed Jerome, a contract carrier operator and an active participant in local self-help groups, to a nearby hospital. His family was informed at the hospital that he had suffered a heart attack. He had three blockages in his plaque-laden arteries (due to unmanaged cholesterol levels), disrupting blood supply to his heart and had to undergo an emergency angioplasty.
Out of danger, Jerome is now a staunch believer in the relevance of cholesterol control in leading a long and happy life.
“My cholesterol levels were always over 300 mg/dL and my bad cholesterol levels were also high. Of the three blockages, one was major, and doctors did an angioplasty to remove that blockade. I have been put on medication for the remaining two. I was lucky that my friends did not waste any time in taking me to the hospital,” Jerome narrates.
Doctors told Jerome that two factors were responsible for his cardiac ordeal – high density lipoprotein (HDL) cholesterol and unhealthy triglyceride levels. This exactly is the reason why low density lipoprotein (LDL) cholesterol became infamous as bad cholesterol. Experts point out that LDL cholesterol is the main agent responsible for atherogenic plaque formation that blocks blood flow to vital organs, including brain and heart, causing heart attacks and strokes.
“LDL cholesterol gets deposited in arteries in our body and compromises blood circulation to the affected parts including the heart, brain, kidney and the peripheral vascular system. It is one of the main reasons for heart attacks and strokes,” says Prof Dr Vitull K Gupta, teaching faculty member at All India Institute of Medical Sciences (AIIMS), Bhatinda, and consultant physician at Kishori Ram Hospital and Diabetes Care Centre, Bhatinda, Punjab, India.
According to experts, a majority of the people are oblivious to the fact that cholesterol has a stronger link with our liver than heart. Contrary to the common assumption that we get cholesterol from the food we eat, the fact is that liver secretes almost 80 per cent of the cholesterol required by our body. Ideally only remaining 20 per cent needs to be supplemented from our daily diet. The main function of cholesterol molecules is to strengthen cell membranes in our body and ensure energy generation through fat metabolism.
But cholesterol being a fatty lipid molecule cannot freely circulate in our bloodstream and has to rely on proteins to do so. Thus, this combination of lipids and proteins is classified as LDL cholesterol, HDL cholesterol and very low density lipoproteins (VLDL). The HDL cholesterol is called good cholesterol and LDL cholesterol is called bad cholesterol, both for valid reasons.
Good vs bad
Cholesterol in the blood becomes an issue when it doesn’t return to its point of origin, the liver, to be broken down and filtered out of the body. It is not the production of cholesterol but this filtration of cholesterol and subsequent ejection of undesirable particles, including LDL cholesterol that matters the most when it comes to managing cholesterol levels. HDL cholesterol ensures that cholesterol in the blood gets circulated back to the liver for the filtration process and hence earned the title of good cholesterol.
However, LDL cholesterol particles tend to get stuck along the arterial walls and do not leave the body and end up forming plaques that constrict and choke our arteries. It is these plaques that eventually end up rupturing and forming blood clots that lead to atherosclerosis. The HDL cholesterol lipoprotein has more protein than lipid in it, whereas LDL is laden with more cholesterol and lipids.
Prof Dr Gupta told Happiest Health that LDL is an unhealthy version of cholesterol, and its level needs to be strictly brought under control to ensure better cardiac health. Dr J Karthick Anjaneyan, Consultant and Interventional Cardiologist, Gleneagles Global Health City Hospital, Chennai, told Happiest Health that when LDL cholesterol level increases in the blood, they form foam cells, which eventually become cholesterol plaques in our arteries. Foam cells are the lynchpins for plaque formation as they attract further deposition of fatty molecules to form plaques.
Excess cholesterol in blood leads to hyperlipidaemia and it becomes a matter of concern if the bad cholesterol levels surpass the prescribed limits as it ends up increasing the risk for atherosclerosis. The cholesterol levels and subsequent risk assessments always depend on and vary according to age, gender, dietary patterns, health comorbidities and even ethnicity. Dr Anjaneyan pointed out to Happiest Health that ideally LDL cholesterol levels should be less than 100 mg/dL for a 20-year-old adult and between 100 to 120 for a 40-year-old and again less than 100 for an individual over 60 years of age.
Triglycerides: The problematic cousin of cholesterol
Until recently the spotlight was always on LDL cholesterol and its harmful effects when it came to heart health. But it has now emerged that triglycerides might also have a role to play in the cholesterol plot. Triglyceride fats have a direct link with our diet and genetic predisposition, especially in the case of South Asians when it comes to cardiac risk assessment. Triglycerides mainly come from the food we consume and their calorific values. Excess calories consumed by a sedentary individual get stored in the body as triglyceride internal fat deposits or are reserved to be used by the body later. Excess internal fat is a major risk factor for multiple cardiovascular conditions, directly and indirectly including diabetes and heart attacks.
“When it comes to South Asians, especially Indians, combination of both triglycerides and LDL cholesterol play a major role and makes it a dangerous proposition for one’s overall cardiac health. It is mainly because of the genetic and dietary factors,” Prof Dr Gupta adds. He also points out that Caucasians and especially Americans always tend to focus on the impact of LDL cholesterol levels, but this might not be applicable to other populations on the same lines.
The liver ensures that triglycerides needed for our body to carry out its physiological processes are attached with VLDL cholesterol molecules and circulated in the body and excess triglycerides get deposited as ectopic fat. Ectopic fat and obesity are among the root causes of diabetes and a host of cardiovascular complications.
“Extremely high triglyceride levels combined with a high-calorie diet and familial conditions could lead to conditions like pancreatitis and indirectly lead to cardiovascular complications including atherosclerosis,” adds Prof Dr Nagamalesh, Ramaiah Medical College and Interventional Cardiologist at Ramaiah Narayana Heart Centre, Bengaluru.
The condition of excess triglycerides in the body is called hypertriglyceridemia, and it is caused when there is excess storage of unused calories as internal fat and also when the body is unable to effectively process and filter out triglyceride-laden VLDL cholesterol molecules.
“In general, isolated high triglycerides themselves are a risk for heart attack, and stroke and when combined with high levels of LDL, these are more detrimental,” added Dr Anjaneyan.
Lifestyle and dietary management
Medical experts claim that lifestyle and diet management are crucial when it comes to cholesterol management. Prof Dr Gupta also points out that unless in acute cases where medication cannot be avoided, lifestyle and diet management play a major role in maintaining healthy cholesterol levels.
“Any medical intervention cannot surpass the benefits of lifestyle modifications. Even if an individual is hale and hearty or if he is suffering from any condition, lifestyle modifications are a must to prevent the onset of disease in the future,” Prof Dr Gupta added.
Jerome, who is presently following a strict dietary and exercise routine to tame his cholesterol levels, points out that he walks for about two hours every morning. He has also stopped consuming processed food and red meat ever since he got discharged from the hospital in September 2021.
“I stopped eating some of my favourite food items, especially papadams (a deep-fried crunchy Indian lentil or rice dough mix) and pickles that are integral to my diet. I have started consuming oats-based food and also watch my rice and wheat intake. I also make sure to dilute milk with enough water before drinking it. I have even joined a local walker’s group that helped me to stay motivated and stick to my daily walking regime,” Jerome says, highlighting the lifestyle changes he has been observing since experiencing the health crisis.
According to World Health Organisation (WHO), cardiovascular disease claims at least 17.9 million lives across the globe annually and more than four out of five of these deaths are due to heart attacks and strokes.
When it comes to dietary fat consumption, there are multiple and contradicting theories. However, a consensus based on the dietary guidelines of WHO indicates that it would be ideal to ensure that the total fat consumption from daily diet does not exceed 30 per cent. It also states that out of this 30 per cent count, saturated fats should constitute less than 10 per cent and the highly problematic trans-fat-rich food should be less than 1 per cent, with special emphasis on eliminating industrially produced trans-fat-rich food.
The general idea would be to restrict the intake of saturated fat-rich food and avoid trans-fat-rich food items – basically processed food items and also those cooked using trans-fat-rich hydrogenated vegetable oils, a profitable option for most of the processed food manufacturers and restaurants across the world. Trans-fat ends up lowering good cholesterol HDL and spiking bad cholesterol LDL. It is also accused of triggering cardiac inflammation and insulin resistance.
“Moderation and smart choice are two key factors when it comes to sustained cholesterol management. If someone wants to have only non-vegetarian food, then it’s a better idea to stick to lean meat. Or if red meat cannot be avoided, then try to also have a plate of fibre-rich vegetable salad along with it to balance off the cholesterol spiking effect of red meat with fibre-rich cholesterol-lowering and HDL-boosting food,” said Sreelakshmi Shenoy, a Kochi-based consultant nutritionist.
The Green Effect in cholesterol management
Simi Thomas, a Kochi based nutritionist at NutrioDietz, told Happiest Health that cholesterol levels cannot be controlled without the inclusion green leafy and fibre-rich vegetables in our diet.
“There are only two ways to control cholesterol: workouts and diet control. Sometimes people with normal total cholesterol levels could have high triglycerides if they are not careful about their diet and daily physical activity routine,” she added.
Most people claim to manage their cholesterol levels by reducing oil intake. However, restricting saturated fats eventually might not prove beneficial if there is no restriction in simple carbohydrate intake, including rice and wheat, as it will eventually end up spiking the triglyceride levels and related comorbidities. Interestingly though, fat-rich food gets blamed for cholesterol and cardiac issues, high calorific value of simple carbohydrates could also contribute to triglyceride levels as it will force the liver to secrete more triglycerides to store the excess unburnt calories as internal fat deposits.
“Carbohydrate intake also has to be restricted and instead fibre-rich food that improves good cholesterol should be added in the daily diet,” Shenoy said.
Dr Anjaneyan also pointed out that to avoid high LDL cholesterol and triglyceride levels, we should avoid oily food, especially the ones that are deep-fried and pan-fried, and opt for more fibre-rich vegetables and fruits and also try to include whole grains in our diet. Shenoy also added that there was no need to completely shun fat-containing items like coconut oil, ghee, egg and butter in fear of cholesterol and assured that these could be consumed in moderation. It has been pointed out that ideally LDL cholesterol should be less than 100 mg/dL and not higher than 40 mg/dL, whereas triglyceride levels should be less than 150 mg/dL.
“If a household requires two litre of cooking oil every month, then they can opt for two different types of oils depending on their taste and budget to ensure better cholesterol management. Sometimes we recommend switching between coconut and canola oil. Olive oil could also be tried if it’s available and fits in the monthly budget,” Shenoy adds.
“Some recent studies point out that coconut oil is not that bad for cholesterol but it all depends on how much oil is being used and the condition in which the food is being cooked,” Thomas added.
She pointed out that olive oil, though is one of the healthiest oils, might lose its nutritional qualities and could even be harmful if overheated while cooking in a traditional iron frying pan.
“Avoiding fried food is always a good option. For example, most fish have oil, which is very good for our health. Technically we could use bare minimum amount of oil to fry fish. We could shallow fry the fish with very little oil in a pan and let the fish simmer in it over a hot flame. But it is time-consuming and needs higher temperature. Even mackerel, which is a commonly cooked fish, has good oil content. Technically, fish already comes with oil that could be used for frying it,” Thomas said.
She also pointed out that this kind of shallow frying on a hot flame for a longer duration is possible if we use old-style iron-based frying pans instead of the new-age non-stick frying pans, which might get damaged. This fish oil is rich in unsaturated fat called omega 3 fatty acids, which according to her, could help us to reduce our triglyceride and cholesterol levels and improve our overall cardiac health.
Cholesterol management tips:
- Always include fibrous green vegetables rich in unsaturated fats
- Avoid processed food rich in trans-fat content if possible
- Restrict saturated fat-rich food and carbohydrate intake
- Avoid smoking and drinking alcohol