What is cholesterol?

There is a difference between cholesterol

Cholesterol is typically measured as the concentration of total cholesterol in the blood as well as the concentration of the subgroups of cholesterol, LDL (Low Density Lipoproteins) and HDL (High Density Lipoproteins). There is also VLDL (Very Low Density Lipoproteins).

LDL and VLDL are the 'harmful' cholesterols. They are known to be so-called atherogenic markers - risk factors that can cause atherosclerosis. LDL is the main culprit, so we will focus on this one first.

Small and dangerous or big and harmless?

Simply measuring the total concentration of cholesterol is not always sufficient to assess the risk of cardiovascular disease. It can be important to measure the number and size of molecules and particle concentration, which is not measured in a standard blood test in the UK. The same concentration of cholesterol can cover many small, dangerous molecules or fewer large, harmless molecules.

LDL molecules can be either large and fluffy or small and very compact (small dense). The 'small dense' LDL molecules (sdLDL) are the dangerous cholesterol molecules that easily penetrate the vessel wall and cause fat deposition and eventually inflammation, i.e. inflammation of the vessels (without bacteria), which is an important part of the mechanism of blood clots. Small LDL molecules (sdLDL) are most commonly seen in people with diabetes or pre-diabetes and possibly metabolic syndrome, which is a disorder in the body's metabolism of nutrients, leading to insulin resistance, high blood pressure and high cholesterol.

You can measure both the number of particles and the concentration of cholesterol in the particles.

LDL particle number is a much stronger marker of disease than LDL concentration. If the particle count is elevated, it is a risk, even if the overall LDL concentration is normal. However, a standard blood test in this case will only tell you that the LDL cholesterol concentration is normal - a normal LDL cholesterol level.

Other markers for cardiovascular disease

There are many other markers that predict the risk of fat deposition in the vessels and thus the formation of atherosclerosis and blood clots.

• Triglyceride is 'free fat' in the blood and is also a risk factor for cardiovascular disease. Triglyceride increases with high intake of sugar, unhealthy fats and alcohol, and decreases relatively quickly when diet and lifestyle changes are made
• Lipoproteins such as ApoA, ApoB and ApoE are generally stronger predictive markers of cardiovascular disease than standard cholesterol measurement. ApoA is related to the previously mentioned HDL (High Density Lipoproteins) and ApoB to LDL (Low Density Lipoproteins). ApoE is a particularly strong marker. If you have a specific variant (ApoE (4/4)), you have a particularly high risk of developing cardiovascular disease and should be included in a special prevention program regarding preventive medication and lifestyle (read more about this below)
• Lp(a) mass and particle concentration is a strong predictive marker for cardiovascular disease. Lp(a) mass is an abnormal type of LDL whose genetics are typically passed down in families, and if elevated, it is associated with an increased risk of heart disease. Lp(a) is most effectively lowered by lowering total LDL cholesterol (see chart below), and Niacin (vitamin B9) is also very effective at lowering Lp(a)
• Homocysteine is an amino acid that in very high concentrations can damage the inside of artery walls and is therefore a risk marker for heart clots in particular
• Hs-CRP is a sensitive marker of whether there is inflammation in the vessel wall; in other words: Is there an ongoing disease process in the vessels that could lead to blood clots?
• Omega3 index in the blood - if this is low, it is a clear risk factor. The key is to have as high an omega3 index as possible, always above 8%. Therefore, if you have a low omega3/6 index, focused omega3 supplementation can be protective against cardiovascular disease

Genetic predisposition

There is a genetic predisposition to cardiovascular disease that can be measured by the ApoE (Apolipoprotein E) genotype. People who have a specific genetic coding for ApoE have a significantly higher risk of cardiovascular disease and it is often very common in these families.

Individuals with this genetic coding are more resistant to both medical treatment and lifestyle modification, but need both interventions. These individuals are much less able to tolerate fats than others, even if they are healthy fats. A cure for people with this genetic coding for ApoE is therefore a very low-fat diet.

Medicine and diet

Cholesterol-lowering drugs, statins, can reduce the number and concentration of cholesterol molecules, but do not affect the size distribution of cholesterol molecules. In other words, there can be an equally skewed distribution of small, harmful cholesterol molecules and large, harmless ones despite treatment with medication.

In contrast, omega3 fatty acids (fish, flaxseed, hempseed, fish oil), low-carbohydrate diets, niacin (Vitamin B9) and niacin in combination with statins (cholesterol-lowering medication), as well as regular exercise and weight loss have all been shown to effectively increase the size of LDL particles.

In this chart, you can get an overview of how you can change the markers and thus the risk of future cardiovascular disease through lifestyle:

What about those eggs? Can you eat them?

It's okay to eat eggs. Eggs are a healthy source of both a mix of fatty acids and protein, and it's best to eat organic eggs to minimize the toxic load. Eggs can be included in the daily diet, but of course, everything in moderation. The recommendations say that you can eat about one egg a day, an average of seven eggs a week, without an increased risk of cardiovascular disease.

Conclusion: The truth is nuanced

All in all, the truth about cholesterol is much more nuanced than what standard measurements can show. When you analyze a typical cholesterol profile blood test, you get numbers on these parameters:

• Total cholesterol (concentration) (must be < 5.0 mmol/l)
• HDL (must be >1.0 mmol/l)
• LDL (skal være <3,0 mmol/l)
• Triglycerid (skal være <2,0 og helst < 1,5 mmol/l)

The individual parameters have limit values (in brackets) that should preferably be adhered to, but there is a very important factor in the relationship between the numbers! Thus, a high HDL can reduce the risk of a high LDL, as the ratio between the two is important. The lower the ratio the better.

How do you know if high cholesterol is dangerous or not?

The easiest way is to get a carotid artery scan and see what your carotid arteries look like. How thick is the vessel wall? If the vessel wall is thickened because of fat accumulation, then yes, you're at risk of damage and future disease.
Is there even plaque formation? And if so, how large and active are those plaques? Are they old changes or are they fresh?
All of this information can be obtained from a simple ultrasound scan.

What to eat if you have "high cholesterol"?

Depending on what the tests show, there may be different advice for each individual. It is always an individual assessment, both in terms of predispositions and current situation, that determines the advice for each person. But overall, there are some common denominators for dietary advice if you are at increased risk of cardiovascular disease:

• First and foremost, minimize the consumption of unhealthy foods, junk food, fast food and prepared foods due to the increased amount of unhealthy fatty acids, salt and sugar
• Next, minimize the intake of fast-absorbing sugars such as soda, candy, cake, etc. as well as chips and foods with very high fat content that are not naturally occurring (processed food)
• At the same time, you can increase the amount of healthy fats such as olives, olive oil, fish, avocado, nuts and almonds, seeds and grains (sesame seeds, sunflower seeds, flax seeds, chia seeds, etc.).
• In terms of animal fats, lean meats are recommended, preferably less red meat in general (and always high quality), more poultry and fish. In addition, dairy products in smaller quantities, including more low-fat cheeses and less butter and cream
• And of course, as always, make sure you get plenty of vegetables and berries and some fruit, as these foods contain plant nutrients that have many beneficial effects

Gain insight into your risk of developing cardiovascular disease

Have you had a high cholesterol level measured in the past and want insight and advice about it? Or do you want to find out if you carry risk markers for developing cardiovascular disease?

With a health check-up, we give you a comprehensive insight into your health. We give you the knowledge you need to adjust your lifestyle and optimize your health. Based on the results of the examination, we help you to prevent any risk factors and boost your wellbeing and quality of life. Read more about our health check-ups here: https://capio.dk/specialer/helbredsundersoegelser/