Dr Jonathan Morrell - Cholesterol

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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.

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Dr Jonathan Morrell - Cholesterol

  1. 1. Sponsored by: "I drive way too fast to worry about cholesterol"
  2. 2. The evolution of manHuman evolution – the shape of things to come?
  3. 3. Normal arterial wall Intima: Endothelium Internal elastic membrane Media: Smooth muscle cellLumen Matrix proteins External elastic membrane
  4. 4. The Unstable Plaque Thinning of the fibrous cap Rupture of the fibrous cap Haemorrhage from plaque microvessels
  5. 5. Plaque rupture and thrombus formation Intraluminal thrombus Lipid pool Intraplaque thrombus
  6. 6. 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
  7. 7. Go back!We ****** up everything!
  8. 8. Outline• What is cholesterol?• Why is it so important?• What can we do about it?• Reality checking
  9. 9. NHS Health Checks
  10. 10. ‘I drive way too fast to worry about my cholesterol’
  11. 11. 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
  12. 12. 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
  13. 13. Atherosclerosis<25y – 22% 25-35y – 47% >35y – 70% Nissen S. Am J Cardiol 2001 87 Suppl. 15A Increasing age Increasing risk factors
  14. 14. INTERHEART Risk Factor PAR (%)Lipids 49.2Smoking 35.7Hypertension 17.9Diabetes 9.9Abdominal obesity 20.1Psychosocial 32.5Lack daily fruit and vegetables 13.7Lack regular alcohol 6.7Lack regular physical activity 12.2
  15. 15. What are lipids?
  16. 16. What is cholesterol?
  17. 17. Why do we need cholesterol?
  18. 18. Where does it come from?
  19. 19. How is cholesterol moved around the body?
  20. 20. The lipoprotein family
  21. 21. Structure of LDL Surface Monolayer of Phospholipids and Free CholesterolApo B Hydrophobic Core of Triglyceride and Cholesteryl EstersMurphy HC, et al. Biochemistry. 2000;39:9763-970.
  22. 22. 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 LibraryRye KA, et al. Atherosclerosis. 1999;145:227-238. www.lipidsonline.org
  23. 23. Rianna’s story
  24. 24. Rianna’s story• Mother and grandmother on statins• Fatty lumps on her knuckles• ‘No need to test yet’• ‘Pinhole’ arteries
  25. 25. Familial hypercholesterolaemia• Eliza Parachute 1851• Autosomal dominant• 1/500• 1/1,000,000
  26. 26. FH-natural history Age ♂ ♀(years) % CHD % CHD40-49 48 750-59 80 51 Slack, Lancet.1969;1380-2
  27. 27. Family history
  28. 28. Family history
  29. 29. 1 in 106 - Homozygous FH Brown and Goldstein identified autosomaldominant LDLR defect in FH fibroblasts in 1974
  30. 30. Family history ? ?? ? ? ? ? ? ? ? What are the duties of care for this family?
  31. 31. INTERHEART Risk Factor PAR (%)Lipids 49.2Smoking 35.7Hypertension 17.9Diabetes 9.9Abdominal obesity 20.1Psychosocial 32.5Lack daily fruit and vegetables 13.7Lack regular alcohol 6.7Lack regular physical activity 12.2
  32. 32. Joint British Societies CVD Risk Predictor Chart
  33. 33. 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’
  34. 34. 22nd April 2008 QRisk © 2008 All rights reserved
  35. 35. 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
  36. 36. 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
  37. 37. 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
  38. 38. Lowering LDL-C• 21% reduction in CV ‘events’ when LDL-C is lowered by 1mmol/L• 40% for 2mmol/L Oxford CTTC
  39. 39. Cholesterol targets Year LDL-C target TC targetGuideline published (mmol/l) (mmol/l)ATP 3a 2004 <1.8ESC/EAS 2011 <1.8JBS 2 2005 <2.0 <4.0NICE (20) 2008 <2.0 <4.0QOF 2003 <5.0
  40. 40. Lower (LDL) cholesterol
  41. 41. Daily Telegraph May 17th 2012
  42. 42. WHO 2002‘….up to 80% of cases of coronary heartdisease and up to 90% of type 2 diabetes couldbe avoided by changing lifestyle factors….’
  43. 43. 0 Observed & Smoking predicted 10Decline 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
  44. 44. 10 tips for a healthy lifestyle1. Balance calorie intake and physical activity to maintain a healthy body weight and shape2. Limit intake of saturated and trans fats and cholesterol3. Substitute saturated and trans fats with unsaturated fats4. Increase omega-3 fatty acid consumption5. Consume a diet rich in fruits and vegetables
  45. 45. 10 tips for a healthy lifestyle6. Choose whole-grain, high fibre foods7. Choose and prepare foods with little or no salt8. Consider plant sterols and soy protein as part of a healthy, balanced diet9. Consume alcohol in moderation10. Avoid use of and exposure to, tobacco products
  46. 46. ‘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
  47. 47. Just an ordinary café?
  48. 48. Its 10 eggs, 10 bacon, 10 sausage, 10 toast, 5 blackpuddings, tomatoes, beans and mushrooms for £10
  49. 49. No chips…..
  50. 50. Eat it all in 20 mins with no drink to wash it down with and you get it free
  51. 51. The breakfast packs in 5,000 caloriesA spokesman forthe British HeartFoundation said:"Eating this amountin one sitting is nota good idea.".
  52. 52. The heart attack grill
  53. 53. 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
  54. 54. Mechanism of ActionCompetition with cholesterol for solubilisation ofdietary and biliary cholesterol in mixed micelles
  55. 55. Overview of clinical trials assessing efficacy of plant sterols plant sterols (g/day) 0.5 1 1.5 2 2.5 3 3.5 0LDL 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
  56. 56. 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
  57. 57. 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)
  58. 58. 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
  59. 59. 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?

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