High cholesterol (hypercholesterolemia)

Cholesterol is an important substance in the body. For example, it forms part of cell membranes and is also used to produce certain hormones, vitamin D and bile acids. However, too much cholesterol in the blood (also known as hypercholesterolemia) can increase the risk of cardiovascular diseases. For this reason, many people worry about their cholesterol levels. 

Cholesterol doesn’t dissolve in water or blood. To transport it in the blood, the body packs cholesterol into tiny parcels, together with various proteins and other components. Based on these other elements in the parcels, the different kinds of cholesterol can be distinguished in a laboratory.

When looking at cholesterol levels, two different types are usually measured. The two types have different effects on health. In everyday language, they are often referred to as “good” and “bad” cholesterol.

• LDL cholesterol (“bad” cholesterol) transports cholesterol from the liver to the rest of the body, where it is used in various processes. However, excess LDL can also be stored. High LDL cholesterol levels are associated with an increased risk of developing cardiovascular diseases. 
• HDL cholesterol (“good” cholesterol) takes excess cholesterol from the body and transports it to the liver, where it is broken down and excreted from the body with bile fluid. High HDL cholesterol levels appear to reduce the risk of developing cardiovascular diseases. 

Hypercholesterolemia, i.e. high cholesterol, occurs when certain levels are exceeded. 

However, opinions differ in regard to what levels are too high. High cholesterol alone tells doctors very little and is not a disease in and of itself. Having a high level of cholesterol in the blood is one of several risk factors for cardiovascular diseases. 

High cholesterol doesn’t cause any symptoms. Very high primary (inherited) high cholesterol sometimes causes deposits to form under the skin, in the tendons or in the eyes.

Cholesterol levels mainly depend on people’s genes and lifestyle.

For most people, the most important factor is lifestyle – in other words, diet and exercise habits. When these factors cause high levels, doctors call this acquired hypercholesterolemia or acquired high cholesterol.

Other diseases, such as an underactive thyroid gland, sometimes lead to elevated cholesterol values. Taking certain medications can also cause blood cholesterol levels to rise somewhat.

Some people already have very high cholesterol as children because of their inherited genetic makeup. There are various forms of this primary or familial hypercholesterolemia, which sometimes can pose a serious health risk. Inherited high cholesterol occurs when a person inherits a mutated gene from their parents, which disrupts the metabolism of LDL cholesterol. Most people inherit this gene from one parent only. The effect is more pronounced if both parents have this type of genetic defect. However, this is extremely rare.

A study by the Robert Koch Institute in 2010 indicated that more than half of all Germans had high cholesterol levels, based on the ranges that are usually considered normal. Therefore, some experts are against the use of pre-defined threshold levels, as they believe that too many people are considered to have a health problem as a result.

As a general rule, the higher the cholesterol level, the higher the risk of developing cardiovascular diseases. But cholesterol isn’t the only risk factor. Many other things can have an influence – both positive and negative. The risk of cardiovascular diseases can only be properly assessed if all factors are considered together.

A person’s individual risk can be determined using special tables or computer programs – this is best done together with a doctor. Information about various risk factors is needed in order to calculate the risk. These include:

• High blood pressure: high blood pressure (hypertension) puts extra strain on the heart and circulatory system.
• Diabetes mellitus: people who have type 2 diabetes have a greater risk of cardiovascular diseases than people of the same age who don’t have diabetes.
• Consuming cigarettes: smoking increases the risk to a greater extent than moderately high cholesterol levels, for example.
• Age: the risk of developing cardiovascular diseases increases with age.
• Sex: men are at a higher risk than women.
• Genetic predisposition: the risk is increased for people with close relatives who suffered a heart attack or stroke at a relatively young age.
• Cholesterol levels: high total cholesterol, high LDL cholesterol (“bad” cholesterol) and low HDL cholesterol (“good” cholesterol) are potentially harmful.

In Germany, people who have statutory health insurance are entitled to a general health check-up every three years from the age of 35. Younger people (between the ages of 18 and 35) can have the check-up once. The aim of this check-up is to detect early signs of cardiovascular disease, diabetes and kidney problems. The examination involves having blood pressure taken, and blood and urine tests, for example. Total cholesterol is measured too.

To determine a person’s cholesterol level, a doctor takes a blood sample to be tested in a lab. Fasting isn’t required, as eating a meal has only a slight effect on cholesterol levels. However, as other blood values are often measured at the same time and these can be elevated shortly after eating, doctors usually recommend fasting before the blood test. In this case, the person should eat nothing and drink only unsweetened tea, coffee or water in the 8 to 12 hours before their blood sample is taken.

These levels can be measured in two different units: either as milligrams per deciliter (mg/dL) or as millimoles per liter (mmol/L). The following levels are considered to be "good" in healthy people:

• Total cholesterol: levels below 200 mg/dL (5.2 mmol/L)
• LDL cholesterol: levels below 130 mg/dL (3.4 mmol/L)
• HDL cholesterol: levels above 40 mg/dL (1 mmol/L) in men and above 50 mg/dL (1.3 mmol/L) in women

Total cholesterol indicates how much cholesterol someone has in their blood overall. High total cholesterol and high LDL cholesterol present a health risk. If the HDL cholesterol level is very low, this is also considered to be of concern. 

Treatment for high cholesterol is not about lowering cholesterol levels. Treatment should instead focus on reducing an elevated risk of cardiovascular disease to as normal a level as possible. 

People who are at an increased risk of cardiovascular disease are often advised to follow some general measures as part of their treatment. These include the following:

• not smoking
• reducing the amount of saturated fats in their diet
• eating a “Mediterranean diet”
• getting plenty of exercise
• losing weight
• if blood pressure is also elevated: eating a low-salt diet

Some of these measures may also lower cholesterol levels.

When assessing the benefits of medications, it isn’t enough to look only at how they affect cholesterol levels. Statins have been shown to lower LDL cholesterol levels and also have other positive effects on blood vessels. As a result, researchers disagree about whether the beneficial effects of statins are only due to their cholesterol-lowering ability or whether other factors play a role too.

The benefits of statins are limited in people who do not have existing cardiovascular diseases – in particular if only their cholesterol levels are elevated and no other risk factors are present. For this reason, their advantages and disadvantages should be discussed with a doctor. Taking preventive medication is also a matter of personal choice.

For more information about reducing the risk of developing cardiovascular diseases without medication, visit gesundheitsinformation.de.

If the risk of cardiovascular diseases is significantly increased, for example, due to coronary heart disease, doctors will usually recommend treatment with statins. 

Statins are also recommended for the treatment of people with inherited high cholesterol and those who have previously had a heart attack, stroke or other cardiovascular diseases. 

Food supplements containing omega 3 or omega 6 fatty acids have not been proven to reduce the risk of cardiovascular diseases. In fact, they may even present a disadvantage – there are some indications that fish oil capsules containing omega 3 fatty acids increase the risk of cardiac arrhythmias (irregular heartbeat), such as atrial fibrillation.

On gesundheitsinformation.de some people with high cholesterol levels share their experiences.