Why cholesterol has a split personality and how the fitness sector can help tackle the growing number of people with high cholesterol levels through positive dietary and lifestyle changes.

1. Sponsored by:
"I drive way too fast to
worry about cholesterol"

3. The evolution of man
Human evolution – the shape of things to come?

4. Normal arterial wall
Intima:
Endothelium
Internal elastic membrane
Media:
Smooth muscle cell
Lumen
Matrix proteins
External elastic membrane

5. The Unstable Plaque
Thinning of the
fibrous cap
Rupture of the fibrous
cap
Haemorrhage from
plaque microvessels

6. Plaque rupture and thrombus formation
Intraluminal thrombus
Lipid pool
Intraplaque thrombus

7. Cerebrovascular disease
Ischaemic stroke
Transient ischaemic attack (TIA)
Cardiovascular (CV) disease
Myocardial infarction (MI)
Angina (stable/unstable)
Peripheral arterial disease (PAD)
Intermittent claudication (IC)
Pain on walking
Acute critical limb ischaemia
Chronic critical limb ischaemia
Rest pain, gangrene, necrosis

8. Go back!
We ****** up everything!

9. Outline
• What is cholesterol?
• Why is it so important?
• What can we do about it?
• Reality checking

10. NHS Health Checks

11. ‘I drive way too fast to worry about
my cholesterol’

12. Atherosclerosis is the leading cause
of death worldwide
Proportion of all deaths (%)
AIDS 5.1
Pulmonary disease 6
Injuries 9.1
Cancer 12.6
Infectious disease 17.8
Atherothrombosis* 28.7
0 5 10 15 20 25 30
Mortality (%)
The World Health Report, 2002, WHO Geneva, 2002

13. CVD – The biggest killer in the UK
• 191,000 deaths from CVD (heart disease + stroke)
• 88,000 deaths from coronary heart disease (CHD)
• 1 in 5 deaths in men and 1 in 8 women
• 124,000 heart attacks each year
• 152,000 strokes
• 2.7 million people live with heart disease
BHF CHD statistics 2010
BHF statistics 2008

14. Atherosclerosis
<25y – 22%
25-35y – 47%
>35y – 70%
Nissen S. Am J Cardiol 2001 87 Suppl. 15A
Increasing age
Increasing risk factors

16. INTERHEART
Risk Factor PAR (%)
Lipids 49.2
Smoking 35.7
Hypertension 17.9
Diabetes 9.9
Abdominal obesity 20.1
Psychosocial 32.5
Lack daily fruit and vegetables 13.7
Lack regular alcohol 6.7
Lack regular physical activity 12.2

17. What are lipids?

18. What is cholesterol?

19. Why do we need cholesterol?

20. Where does it come from?

21. How is cholesterol moved around the
body?

22. The lipoprotein family

23. Structure of LDL
Surface
Monolayer of
Phospholipids
and Free
Cholesterol
Apo B Hydrophobic Core
of Triglyceride and
Cholesteryl Esters
Murphy HC, et al. Biochemistry. 2000;39:9763-970.

25. Structure of HDL
Surface Monolayer of
Phospholipids and
Free Cholesterol
Apo A-I
Apo A-II Hydrophobic
Core of Triglyceride
and Cholesteryl
Esters
Slide Source
Lipids Online Slide Library
Rye KA, et al. Atherosclerosis. 1999;145:227-238. www.lipidsonline.org

26. Rianna’s story

27. Rianna’s story
• Mother and
grandmother on
statins
• Fatty lumps on her
knuckles
• ‘No need to test
yet’
• ‘Pinhole’ arteries

28. Familial hypercholesterolaemia
• Eliza Parachute 1851
• Autosomal dominant
• 1/500
• 1/1,000,000

29. FH-natural history
Age ♂ ♀
(years) % CHD % CHD
40-49 48 7
50-59 80 51
Slack, Lancet.1969;1380-2

30. Family history

31. Family history

32. 1 in 106 - Homozygous FH
Brown and Goldstein identified autosomal
dominant LDLR defect in FH fibroblasts in 1974

33. Family history
? ?
? ?
? ? ?
? ? ?
What are the duties of care for this family?

38. INTERHEART
Risk Factor PAR (%)
Lipids 49.2
Smoking 35.7
Hypertension 17.9
Diabetes 9.9
Abdominal obesity 20.1
Psychosocial 32.5
Lack daily fruit and vegetables 13.7
Lack regular alcohol 6.7
Lack regular physical activity 12.2

40. Joint British Societies CVD Risk Predictor Chart

41. Communicating risk
• Studies show high risk individuals can be motivated
to reduce their risk if their risk status is
communicated effectively
• ‘Your CVD risk is 31% over 10 years’

42. 22nd April 2008 QRisk © 2008 All rights reserved

43. Communicating risk
• 4/5 people at high-risk are inappropriately optimistic
• 1/5 people at low-risk are inappropriately pessimistic
Van der Weijden T et al. Curr Opin Cardiol 2008;23(5):471-6

44. Communicating risk – HEART AGE
• Concentrates on the modifiable proportion of risk
• Compares the Heart Age of the subject with a person
of the same age whose risk factors are ideal
• For example, a 61 year-old woman has a 10-year CV
risk of 10.5%. Her ‘normal’ risk should be 6.7%. The
57% increase in relative risk extrapolates to a Heart
Age of 73
Cobain M et al

45. What are typical cholesterol values
in the UK?
5.3/5.4 mmol/L
HSE 2006 (N.B. effect of age and treatment)
Typical LDL-C of people with a heart attack is
3.8 mmol/L

46. Lowering LDL-C
• 21% reduction in CV ‘events’ when
LDL-C is lowered by 1mmol/L
• 40% for 2mmol/L
Oxford CTTC

47. Cholesterol targets
Year LDL-C target TC target
Guideline
published (mmol/l) (mmol/l)
ATP 3a 2004 <1.8
ESC/EAS 2011 <1.8
JBS 2 2005 <2.0 <4.0
NICE (20) 2008 <2.0 <4.0
QOF 2003 <5.0

48. Lower (LDL) cholesterol

50. Daily Telegraph May 17th 2012

53. WHO 2002
‘….up to 80% of cases of coronary heart
disease and up to 90% of type 2 diabetes could
be avoided by changing lifestyle factors….’

55. 0
Observed &
Smoking predicted
10
Decline in mortality, %
decline in CHD
Blood pressure death in
20 Finnish men,
35 - 64
Cholesterol
30
Predicted (all
risk factors)
40
50
Observed (all risk factors)
60
1972 76 80 84 88 92
Year Vartiainen E,
BMJ 1994; 309: 23

56. 10 tips for a healthy lifestyle
1. Balance calorie intake and physical activity to
maintain a healthy body weight and shape
2. Limit intake of saturated and trans fats and
cholesterol
3. Substitute saturated and trans fats with unsaturated
fats
4. Increase omega-3 fatty acid consumption
5. Consume a diet rich in fruits and vegetables

57. 10 tips for a healthy lifestyle
6. Choose whole-grain, high fibre foods
7. Choose and prepare foods with little or no salt
8. Consider plant sterols and soy protein as part of a
healthy, balanced diet
9. Consume alcohol in moderation
10. Avoid use of and exposure to, tobacco products

58. ‘The new diet rules’
• Drink full fat milk not skimmed
• Eat full fat cheese/yoghurt
• Eat two eggs a day
• Buy butter not margarine
• Use coconut oil
‘People with high levels of blood cholesterol don’t have
worse health outcomes than those with lower ones.’
The Times March 17th 2012

59. Just an ordinary café?

60. It's 10 eggs, 10 bacon, 10 sausage, 10 toast, 5 black
puddings, tomatoes, beans and mushrooms for £10

61. No chips…..

62. Eat it all in 20 mins with no drink to wash
it down with and you get it free

63. The breakfast packs in 5,000 calories
A spokesman for
the British Heart
Foundation said:
"Eating this amount
in one sitting is not
a good idea.".

64. The heart attack grill

67. Cholesterol reduction by diet
Dietary Dietary change Approximate LDL-C
component reduction in %
Saturated fat <7% of energy 5-10
Plant sterols 2-2.5 g/day 10
Dietary cholesterol <200 mg/day 5
Viscous fibre 5-10 g/day 5
Soya protein 25 g/day 5
Body weight Lose ~5 kg 5
management
Adapted from Jenkins et al. Curr Opin Lipidol 2000

68. Mechanism of Action
Competition with cholesterol for solubilisation of
dietary and biliary cholesterol in mixed micelles

69. Overview of clinical trials assessing
efficacy of plant sterols
plant sterols (g/day)
0.5 1 1.5 2 2.5 3 3.5
0
LDL cholesterol (% change)
2–2.5 g of plant sterols
-4 daily significantly
reduces LDL
cholesterol by ~10%
-8
-12
-16
41 trials with plant sterols/stanols:
LDL cholesterol
95% CI from meta-analysis
Katan et al. Mayo Clin Proc 2003

71. The ‘Portfolio Diet’
• Breakfast oatbran, orange, Metamucil (psyllium), oatbran
bread, PS margarine, double fruit jam, soy milk
• Snack almonds, soy milk
• Lunch vegetarian chilli, oatbran bread, PS margarine, soy
slices, tomato, orange
• Snack almonds, Metamucil, soy milk
• Dinner vegetable curry, soy burger, beans, barley, okra,
aubergine, cauliflower, onions, red pepper
• Snack soy yoghurt, Metamucil, jam

72. A dietary portfolio effectively
reduces LDL cholesterol levels
Week 0 Week 2 Week 4
0
LDL cholesterol (% change )
-5
-8.5%
-10
-15 Control diet
Control diet + statin
-20
Dietary portfolio#
-25
-30 -29.6%*
-33.3%*
-35
34 adults,
4 week interventions
#Dietary portfolio = plant sterols, soy protein, viscous fibre, Jenkins et al. AJCN 2005
*Significantly different from control (low saturated fat diet)

74. Tom
• Asymptomatic
• Non-smoker
• 124/62
• Father died MI 49,
paternal grandfather
sudden death 54
• 2 sons aged 8 and 9
• 2 brothers, 1 sister
TC 9.9 HDL 1.4

75. Why is cholesterol so important?
• Essential for life
• Key player in the development of arterial
disease
• Effects can be modified by diet and drugs
What are YOU going to do about it?