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Q&A on cholesterol



Assoc. Prof. Dr. Nasır Sivri, Trakya University Cardiology Section, Edirne



Hypertension, lipid (fat) disorder, smoking, diabetes, obesity, less physical activity and sedentary living, high hematocrit, increased trombogenic factors, age, male gender, family disease history, type A personality, lack of estrogen, drinking, high fibrogen, high uric acid, lipoprotein, disorder in the brain, heart, kidneys or nerves.

Hypertension is an important risk factor for cardio health at every age and gender and this risk increases paralel to the increase of high and low blood pressure. Treating hypertension reduces cardio risk.

Lipid (fat) system disorders are among the major but correctable cardio risk factors. All research has shown a connection between serum cholesterol levels and cardio risk. Low HDL is also a cardio risk factor.

The connection between obesity and coronary vascular disease has been proven. However, overweight patients are more under the risk caused by hypertension, absence of physical activity, diabetes and lipid disorder.


What does heart protective exercise mean?

This means walking for 30-45 minutes daily with a tempo and non stop (like you are trying to reach somewhere). Taking such walks 6 days out of 7 is ideal and on the seventh day you should do a little jog (it should make you sweat).


What is cholesterol?

Is among the basic constituents of all our cells. It is used to construct cell membrane and certain hormones but is harmful if found in large amounts in the blood. While some of the cholesterol found in the blood is produced in the liver, the rest is taken from food. Animal products like meat, dairy products and egg contain cholesterol. There is no cholesterol in fruit, vegetables or grains.


Why is cholesterol so important?

High cholesterol increases the risk of heart-vascular disease. The higher cholesterol means higher cardiac risk. Cardiac illness is the primary factor for death of women and men and around the world.


What is good (HDL) and bad (LDL) cholesterol?

Cholesterol is carried from the liver to the cells and from the cells to the liver through the blood. Cholesterol doesn’t dissolve in blood and is carried in packets called lipoproteins. There are two types that transport cholesterol: LDL, known as bad cholesterol and HDL, known as good cholesterol. Total cholesterol/HDL ration should be higher than 4.5.

High LDL in blood could make cholesterol stick to the inner surface of nerves and create plaques. These plaques grown when substances other than cholesterol stick to them. Cracks that surface on the plaques could form blood clots and clog the nerves. Clogging in the nerves is the cause of heart attack and brain paralysis.

Cholesterol is transported in blood in packages known as HDL cholesterol. HDL prevents cholesterol from accumulating in blood. People with high HDL have less chances of getting a stroke. Research by the Turkish Cardiology Association has shown that HDL levels are low among Turkish people. Smoking and obesity lower HDL while regular excersize increases it.


What should normal cholesterol levels be?

Total cholesterol, LDL and HDL should be:

   Total cholesterol                            LDL cholesterol                                     HDL cholesterol

Normal   less than 200 mg/dl             less than 130 mg/dl                                  more than 40 mg/dl

Boundry/high  200-240 mg/dl            130-159 mg/dl

High   more than 240 mg/dl               160 mg/dl and above more than 60 mg/dl


Does everyone start cholesterol drugs due to same cholesterol factors?

No, it is necessary to see a person’s age and whether they have additional risk factors. The decision to start cholesterol drugs is taken according to whether the person has a any vascular diseases or other risk increasing factors. For instance, a pre-menopause woman with high HDL and no other risk factors would face no risk with 235 mg/dl while the same level would require taking medicine for a 50 year old male with cardiac problems.


How often should cholesterol be measured?

Everyone above the age of 20 should get their cholesterol, triglyceride and HDL levels every five years. LDL isn’t measured directly but is calculated according to a Formula (LDL=Total cholesterol – (HDL + Triglyceride / 5)


Can cholesterol be high without causing any discomfort?

High cholesterol may not lead to any complaints. Diseases like heart trouble and paralysis surface many years after cholesterol has started accumulating on the surface of nerves. This is why people above 20 should find out the cholesterol levels in their blood and practice the appropriate lifestyle. People who know that their parents or siblings have suffered from coronary problems, diabetes or hypertension in early ages must get their cholesterol checked and adopt the necessary measures.


What should triglyceride levels be?

Triglyceride is the form of cholesterol as found in nature. It is both produced in the body and consumed through food. High levels in the blood increase cardiac risk. It is the second fat in the blood that is reduced after LDL.

Classification                      Triglyceride levels

Normal                                 less than 150 mg/dl

Border/high                          150-199 mg/dl

High                                      200-499 mg/dl

Very high                              500 mg/dl and above


Do cholesterol levels differ among people and societies?

Different groups of people have different average cholesterol levels. Cholesterol and triglyceride levels depend on hereditary and environmental factors as well as many factors like the absorption of fats, processing them in the liver, their production, absorption by cells and being returned to the liver after cells break down. Differences in diet is another reason.

People who consume too much of saturated fat have higher cholesterol levels and witness cardiac failure more frequently.


What are other risk factors leading to cardiac disease?

- Risk is higher in 45-50 year men and women over the age of 55
- Family  history: if there is heart trouble in relatives closest in the blood line
- High blood pressure (over 140/90 mm Hg)
- Diabetes
- Smoking
- Obesity: weighing more than height, having more fat around the belly area increase cardiac risk. The waist being wider than 102 cm in men and 88 cm in women increases risk.)

Having high cholesterol and triglyceride levels increases risk of heart trouble.


How often should we have a cholesterol test done?

Fat levels in the blood should be checked at least once a year after 18-20.

High cholesterol could be hereditary. Having cholesterol even above 300 might not cause any discomfort. If there are no family members with heart disease then controls can be done once every 5 years. However, you should get your cholesterol checked once a year if you have relatives in the closest bloodline with heart trouble. Everyone above 40 should get their total cholesterol, LDL, HDL and triglyceride levels checked.


Can we know about possible heart disease beforehand if we get our blood levels checked?

Yes, it can inform us before we get heart trouble. It is important to diagnose high cholesterol early and to take measures accordingly. Adopting a cholesterol healthy diet, quitting smoking, following blood pressure and diabetes closely and doing regular excercise could be sufficient.


How is high cholesterol treated?

Starting a diet is the first thing if cholesterol is between 200-240. A few months of diet and excersize should be pursued with a blood test on the sixth month. Diet and excersize can bring cholesterol below 200. However, if cholesterol is stil high despite diet and excersize, it means you are tiring out your liver too much. You might need to take medicine in this case. Apart from medication, it is also advisable to reduce activity of the right sympathetic nervous system and heat in the liver (see footsoaking in Sahaja Yoga and applying ice to the liver).


How does medication help?

All cholesterol medication can be found in Turkey. However, starting medication does not mean you should quit excersizing and your diet. It has been observed that patients start consuming meat products more after starting medication.


Does medication have an adverse effect on the liver?

This medication rarely has side effects. 99% of people do not have any problems but medication must always be taken with doctor’s control.


Which emotions increase cholesterol?

Frequent anger, reacting to things too much, fear, hyperactivity, tension and chronic stress, depressive feelings leading to insomnia.


Which diseases increase cholesterol risk?

Hereditary fat related disorders, hypothyroid (slow functioning of the thyroid gland), liver diseases, diabetes, kidney disorders (nephritis)


Can cholesterol lead to high blood pressure?

High cholesterol is widespread all over the world. Cholesterol harms the structure of the nerves and leads to arteriosclerosis in time. This creates high blood pressure in older age.


How come cholesterol levels aren’t going down despite medication?

This could be due to a different disease and this should be looked into. Slow functioning of the thyroid gland (hypothyroid), liver disorders, kidney infections (nephritis), diabetes and some drugs can all lead to high cholesterol. If these do not exist, it might be due to your lifestyle. For instance, the person’s diet might be bad or excersize insufficient.


Medicine free and practical home remedies for cholesterol


Traditionally people have been keeping the soft part inside the walnut in a glass of water from night until morning and drinking the yellow water that forms and eating the walnut pieces on an empty stomach in the morning.

Scientific research has shown the positive effect of walnuts. Polyphenolic compositions found on the yellow layer on walnut seeds pass on to water. Polyphenolic compositions have strong anti-oxidant qualities, thus preventing LDL cholesterol from turning into oxide and becoming more harmful. Unsaturated fatty acids in walnut seeds are also known to control cholesterol. Therefore, eating walnuts has a practical effect.

LDL cholesterol can be reduced by 10-15% by following this. This is a good level for medium risk cholesterol patients but is not enough for high risk people.


Is the cholesterol reducing effect of walnuts linked to diet?

No, the effect of walnuts on cholesterol levels is independent of diet. Research for 12 months on 87 volunteers with normal or medium high cholesterol levels proved the following: half of the volunteers did both a diet and ate walnuts while the other half weren’t given a diet. The group consuming walnuts quit the diet after six months and were allowed to consume the food they wanted to together with walnuts. The group that had previously been given just walnuts was given a diet also. Blood tests were carried out before, after and on the 4th, 6th, 10th and 12th months for five times in all.

Results showed that whether taken with or without  a diet, walnuts had a significant reducing effect in cholesterol and triglyceride levels in patients with high cholesterol. A significant reduction was achieved in malignant cholesterol, LDL but no effect was seen on HDL.


How does walnut effect people with normal cholesterol levels?

There isn’t much difference.


How does the consumption of walnuts and fish effect cholesterol levels?

Walnuts contain vegetable Omega-3 while fish contain sea-related Omega-3. Research has shown that people with normal or high cholesterol can reduce total cholesterol and LDL levels by consuming 40 grams of walnuts every day.

This has a better effect than the fish diet – consuming 250 grams of fish a week. However, consuming fish regularly reduces triglyceride levels more than walnuts do and increase HDL more in comparison as well.

Resesarch indicates that a walnut diet should be followed if you want to reduce total cholesterol and malignant cholesterol (LDL) whereas a fish diet should be adopted if you want to increase good cholesterol (HDL) and lower triglyceride.


How much of meat-fish-poultry should I eat while trying to keep cholesterol in check?

Meat or vegetables? Vegetables are better but if you feel like having meat then prefer white meat. Fish is better than poultry. Do not eat the skin and fat in chicken and eat it without frying. Prefer calf meat if you wish to consume red meat.
How much olive oil should I use?

You can use as much olive oil as you want because it reduces cholesterol! 25-30% of daily energy should be taken from oils. 8-10% of these oils should be from saturated fat, 10% from unsaturated, 10-15% from polyunsaturated fatty acids.

Olive oil is a mono unsaturated fatty acid.

You shouldn’t forgt the polyunsaturated fats as well. Corn oil or mixing equal amounts of soya or sunflower oil for food is also good.


How do dried nuts help?

Fatty seeds like hazelnuts, walnuts and almonds should be included in the diet because they contain precious fatty acids that are good for your heart. However, cholesterol isn’t reduced due to high fat levels in fatty seeds . 10 hazelnuts and 2 walnuts are usually sufficient for a day.


Milk and dairy products?

Are important because they contain all nutrients as opposed to other food groups. Must be consumed in a limited amount daily due to their high saturated fat levels. Milk, cheese and yoghurt should be preferred with little fat or fat free to decrease saturated fat intake.


What type of fat does food contain?

Are divided into three: saturated, unsaturated and polyunsaturated fat. Solid oils contain saturated, liquid oils contain  unsaturated fat in high levels. Saturated fat in diets increase cholesterol. Saturated fat is high in lamb meat, calf meat, fatty milk and its products and hard margarine. Polyunsaturated fatty acids exist in sunflower and corn oil while mono unsaturated fat is found in olive oil.


Animal products?

Include poultry, fish and red meet. They contain certain amounts of cholesterol and should be consumed in limited amounts. The important thing is the frequency and amounts of consumption. Fat free red meat should be taken 100 grams a week once or twice.


Should the diet include eggs?

Research in the US in March 2010 showed that:

Overweight people with high cholesterol should not remove eggs from their diet because eggs contain high protein and are a rich source of Vitamin D. This is why it should be consumed 2-3 times a week, unfried.

80 calories taken from an egg keeps a person full for a long time. B12 vitamins taken from egg play a vital role in burning fat cells and removing fat from the body by dissolving it!

Eggs contain a rich combination of amino acids and are very important for the health of children. Eggs are also rich in anti oxidants and are a very good for antiaging.


Is too much of eggs harmful?

One big egg contains 210-220 mg of cholesterol. You can take 3-4 boiled, not fried, eggs a week as omlet on an unfried pan or with lots of vegetables.


What is the effect of wheat, rice and barley?

You should take more of pulpy foods. Wheat, rice and barley contain nutrients that prevent the formation of cholesterol in the liver and reduce cholesterol levels in the blood. Pulp helps the body throw out cholesterol. Prefer wheat or rye bread.


What do you suggest to reduce cholesterol?

This depends on a proper diet. consume a lot of pulpy foods, more fruit, vegetables and salads and avoid fried food.

Prefer the fruit itself to fruit juice. Fruit that can be consumed with its skin should be taken as a whole. Prefer white rice to cracked wheat. We should include protein rich grains in our diet 2-3 times a week.

Desserts should be taken once or twice a week. Milk puddings with high calcium should be preferred to protein rich desserts made of white flour. Avoid white sugar if you are overweight and take drinks without sugar or sweeteners.

A heart friendly diet

1. Overweight people should reduce their calorie intake and shed off excess kilos with more excersize. Putting on weight increases cholesterol as well.

2. Prefer fat free meat and reduce red meat as much as possible

3. Salami, sausages and such meat products contain high saturated fat and should be eaten less

4. White meat is better than red. Grilled, boiled or poached meat is better than fried.

5. Fish is good for the heart. Shrimps and squid are rich in fat.

6. We do not suggest everyone to take fish oil as daily medicine.

7. Cake, cream and icecream usually contain saturated fat and so should be consumed less

8. Pulp that can dissolve reduces cholesterol. Oats, rye, beans, peas, rice, oranges and strawbery contain a lot of this. wheat, carrots, turnips, cabbages, cauliflower, the shell of fruit contain pulp tha does not dissolve. Such pulp doesn’t effect cholesterol but helps the intestines work.

9. 3-4 eggs a week


What else can I do to protect my heart apart from watching out for my diet?

1. Excess kilos must be lost, daily excercise is  a must!

2. Regular excercise increases HDL and reduces LDL

3. 30-45 minute walks 3-5 times a week, sports like swimming and cycling are good

4. A brisk walk 30-45 minutes daily is the best exercise

5. Quit smoking

6. Adjust your diet if you have high blood pressure (reduce salt)

7. Control diabetes

Small amounts of alcohol increase HDL a bit but alcohol cannot be advised to protect your heart due to its negative effects. HDL increased in such a way is not known to protect the heart.

You must take the drugs prescribed by your doctor if you fail to reduce your cholesterol and triglyceride levels with your diet and lifestyle changes. Most patients who have had heart attacks or suffered from paralysis use such medication.

This prevents recurrence of the sickness.


How long should I follow a diet, take medicines and follow a specific lifestyle to be able to reduce cholesterol?

Leading a correct lifestyle as of childhood is very important and this should be continued lifelong. This is the only way to reduce frequency of heart trouble. People with heart trouble, paralysis or other risk factors should take drugs with doctor’s advice life long if they cannot reduce their cholesterol with a specific diet and lifestyle.


Which medicines reduce cholesterol?

Groups of medicine that reduce LDL:

- Statins
- Nicotinic acid
- Gemfibrozil
- Kolesteramin
- Ezetimib

HDL should not be lower than 40 mg/dL. Each 1% increase in HDL will reduce coronary heart disease risk by 2-4%.

Niacin is more effective than gemfibrozil statins in increasing HDL. Statins reduce LDL much more. Fenofibrat increases HDL most.


In which situations is the reduction of LDL helpful?

Reducing LDL helps prevent plaque formation in the veins, makes existing ones smaller and prevents existing plaques from tearing. This prevents the formation of clots. It reduces chances of a stroke by making coronary artery disease better. It also prevents a paralysis by reducing clogging in the nerves of the brain.


Who are high risk patients?

- Those who already have coronary heart disease (those with previous heart infarct)
- Arterosclerosis in other arteries (palsy, TIA, trouble in the nerves of the feet)
- Those fitting two or more risk factors (smoking, hypertension, early strokes in other family members)


Very high risk patients?

- People whose chances of getting a second stroke within the next 10 years of the first one are higher than 20%
- Together with coronary artery disease:

1. Having multi risk factors (like diabetes)
2. Having serious or uncontrolled risk factors (inability to quit smoking, etc)
3. Metabolic syndromes  (obesity, high blood pressure, high triglyceride levels, low HDL, insulin resistance)
4. People hospitalized due to acute coronary syndrome


Medium high risk patients?

- People who have 2 or more risk factors but who don’t have coronary artery disease or diabetes. People whose chances of getting a second stroke within the next 10 years of the first one are between 10- 20%.


Medium risk people?

- People whose chances of getting a second stroke within the next 10 years of the first one are less than 10%.


Low risk people?

0 or no coronary risk factors


Practical advice for daily life:

In your plans:

Set aside at least 30 minutes out of your day’s 24 hours for regular excercise. Regular excercise reduces chances of diabets, hypertension, high cholesterol, obesity and related illnesses. Minimizes stress and related diseases.



Prefer walking to driving as much as possible. Health improves with more excersize.


Eat less fat cheese like goat’s cheese. Avoid salami, sausages and such food.


Avoid shrimp and squid. Prefer larger fish and grilling.


Prefer grilled calf meat, chicken, chicken breast. Avoid chicken skin, lamb and red meat.

Eating out:

Avoid mixed sauces and maionnaise. Prefer olive oil and lemons. Fish, chicken and salads are best. Prefer veggies or tomato sauce for pasta.

As a result, cholesterol depends on leading the right lifestyle. Positive attitudes must be adopted as of childhood and regular excercise must be followed lifelong.