Why does the body need cholesterol and where does it come from?
Cholesterol is part of the membrane of every cell and gives it the necessary density and mobility. Without it, bile acids are impossible, without which fats cannot be absorbed, vitamin D synthesis in the skin is impossible, cortisol, testosterone and estrogens are impossible. That is why the human body does not rely on supplies from the outside: the liver produces a significant part of cholesterol on its own, and produces exactly as much as needed.
- Building material of the membranes of all cells, especially nervous tissue
- Basis for the synthesis of bile acids involved in the digestion of fats
- A precursor to vitamin D, which is formed in the skin under ultraviolet light
- Precursor to cortisol, aldosterone and sex hormones
- Participant in signal transmission between cells and brain function
This leads to a practical conclusion that surprises many: dietary cholesterol affects blood cholesterol levels much less than is commonly thought. The liver works on the principle of a thermostat - when food intake increases, it reduces its own synthesis, and when it decreases, it increases it. Saturated and industrial trans fats are much more important because they change the very rate at which lipoproteins are produced and processed, rather than simply adding cholesterol molecules to the bloodstream.
LDL and HDL: why one number doesn’t solve anything
Fats do not dissolve in the blood and travel in protein-fat containers - lipoproteins. Different containers do exactly the opposite job, which is why the “total cholesterol” line on the form is not very informative: it sums up what is harmful and what is protective into one figure.
- Low-density lipoproteins (LDL) are the main transporter to tissues. Their excess penetrates the artery wall, oxidizes and triggers the formation of plaque. This is the main target of treatment
- High-density lipoproteins (HDL) - reverse transport, take excess cholesterol from tissues to the liver. Low level is an unfavorable sign
- Triglycerides are “fuel” and energy reserves. They increase from excess sugar, alcohol and excess weight, and very high values threaten pancreatitis
- Non-HDL cholesterol is a common minus of HDL. A simple and reliable indicator, especially if triglycerides are elevated
- Lipoprotein(a) is a genetically determined indicator that hardly changes with lifestyle. It is enough to determine it once in a lifetime, usually with early vascular events in the family
- Apolipoprotein B is actually a counter of atherogenic particles, more accurately reflects the risk than the mass of cholesterol in them
This is a typical mistake when reading analysis. A total cholesterol of 5.8 mmol/L in a person with high HDL and low triglycerides may be a completely calm picture, but the same 5.8 mmol/L in a person with an HDL of 0.8 mmol/L, triglycerides of 3.0 mmol/L and a waist circumference of 105 cm is an alarming picture. The same line in the form, a fundamentally different meaning.
Which numbers are considered yours?
There is no one size fits all, and this is the key point. The target LDL value depends on the total risk: the higher the probability of a vascular accident, the lower the indicator should be lowered. A 30-year-old person without risk factors and a person who has had a heart attack, given the same analysis, will be prescribed completely different things.
- Низкий риск — молодой возраст, нормальное давление, отсутствие курения и диабета: ориентир для ЛПНП около 3,0 ммоль/л, обычно достаточно образа жизни.
- Умеренный риск — есть отдельные факторы, но сосудистых событий нет: ориентир примерно 2,6 ммоль/л.
- Высокий риск — выраженная гипертония, длительный диабет, значительное поражение почек, очень высокий холестерин: ориентир около 1,8 ммоль/л.
- Очень высокий риск — перенесённый инфаркт или инсульт, подтверждённые бляшки в артериях, диабет с осложнениями: ориентир около 1,4 ммоль/л и снижение не менее чем наполовину от исходного.
- Триглицериды желательны ниже 1,7 ммоль/л, ЛПВП — выше 1,0 ммоль/л у мужчин и выше 1,2 ммоль/л у женщин.
That is why the debate “5.5 is a lot or normal” is meaningless in isolation from a person. The doctor calculates the risk by age, gender, blood pressure, smoking, cholesterol level and concomitant diseases, and only then names the goal. This also explains why two people with the same analysis are given different recommendations: the difference is not in the analysis, but in everything else.
What Really Works in Diet and Lifestyle
Nutrition affects lipids less than advertising promises, but much more than skeptics believe. A realistic target: smart changes in diet and activity reduce LDL by about a tenth to a fifth. For a person with a moderate risk, this may be completely enough, for a person after a heart attack - not, but even there, nutrition enhances the effect of medications.
- Reduce saturated fats: fatty meats, fat tail fat, butter, cream, high-fat cheeses. Replace them with vegetable oils, nuts, fish
- Completely remove industrial trans fats - margarines, cheap baked goods, ready-made puff pastries, fast food
- Add soluble fiber: oats, barley, legumes, apples, vegetables. It binds bile acids and causes the liver to waste cholesterol
- Fish twice a week; a small handful of nuts daily, but adjusted for calorie content
- Sharply limiting sugar, sugary drinks and alcohol is the main lever for triglycerides, not LDL
- Moderate aerobic activity of at least 150 minutes per week: brisk walking, cycling, swimming
- Losing even a few kilograms of weight significantly improves triglycerides and HDL
- Quitting smoking is the only measure that both increases HDL and removes a powerful independent risk factor
It is worth mentioning separately about the timing. It makes sense to repeat the lipidogram no earlier than 6–8 weeks after changing the diet or starting therapy: before that, the indicators simply do not have time to settle. Frequent retakes “in two weeks” lead to disappointment and the false conclusion that nothing helps.
Statins: what they fear and what is actually known
Statins are the most discussed and most mythologized group of drugs. They work not only by lowering LDL: they reduce inflammation in the vessel wall and tighten the plaque cap, making it less prone to rupture. That is why the benefits are visible already in the first months of use, long before any changes in the size of the plaques.
- Muscle pain is the most common reason for refusal. In blinded studies, where neither the patient nor the doctor knew what the person was taking, the incidence of muscle complaints on the statin and the pacifier was almost the same. This does not mean that the complaints are fictitious: they are real, but for the majority they are associated with anticipation, and not with the drug
- True muscle damage with severe weakness and dark urine is very rare and requires immediate cancellation and consultation with a doctor.
- Liver: a slight increase in enzymes is possible, but serious liver damage is a casuistry. Monitoring liver tests before and some time after the start is sufficient
- A slight increase in blood sugar in predisposed people has indeed been described, but the benefit in heart attacks and strokes is noticeably outweighed
- Memory deterioration was not confirmed during long-term observations
- Taking it in the evening was important for short-acting drugs; modern ones can be taken at any time of the day
A separate and much more real problem is unauthorized cancellation. Statins are not a course of treatment: they work while they are taken, and after stopping, lipoprotein levels return to baseline within a few weeks. The situation “I drank for three months, the analysis was good, I quit” is not a victory, but a return to the beginning. If the drug is not suitable for some reason, the doctor’s task is to replace it or change the dose, and not leave the person without treatment.
When it's not about food: familial hypercholesterolemia
There is a particular situation in which talking about nutrition is almost meaningless. Familial hypercholesterolemia is an inherited disorder in which cells are less able to take up LDL from the blood. A person can be thin, athletic, not eat fat, and still have very high cholesterol from birth. It is not at all as rare as it is commonly thought, and most often remains unrecognized until the first heart attack.
- LDL persistently above 4.9 mmol/L in an adult or total cholesterol above 7.5 mmol/L without obvious reasons
- Early heart attacks and strokes in the family: in men under 55 years of age, in women under 65 years of age
- High cholesterol in immediate family members, including children and adolescents
- Dense thickenings on the Achilles tendon and on the tendons of the dorsum of the hand
- A light ring along the edge of the cornea that appears before the age of 45
- No effect from the diet - indicators hardly change
The key practical step here is cascade screening: if the diagnosis is confirmed in one person, a lipid profile is given to all first-degree blood relatives, including children. This is a case where one test in an adult can change the fate of several people in a family, because early treatment advances the age of the first vascular event by decades.
