Some patients of mine often report no significant change in their levels of bad cholesterol, or low-density lipoprotein (LDL) despite correcting their diet, lifestyle and taking up an exercise plan. Obviously, they get demotivated. But what they do not know is that while eating clean and dedicated physical activity do reduce cholesterol, in some cases lifestyle modification is just not enough without medication. That’s because most Indians, while being conscious about their LDL counts, do not understand their nature.
While dietary interventions can keep LDL in check, elevated levels need additional intervention with drugs. LDL has many sub-categories, large, medium and small. The last are not only small but dense particles that can permeate cell membranes easily and circulate in the blood. While the total LDL counts of Indians are usually lower than Caucasians, the proportion of small density LDLs is higher. These are more toxic for the walls of the blood vessels. That’s why, given their sticky and stubborn nature, they need to be controlled aggressively with drugs and lifestyle corrections. Studies have shown that those with an abundance of small LDL have a 300 per cent heart disease risk than people with large LDL. This explains why approximately 50 per cent of people who suffer a heart attack have ‘normal’ total blood cholesterol levels.
WHAT SHOULD YOUR SAFE LDL LEVELS BE?
Usually, the accepted near optimal is considered to be 100 to 129 mg/dL while 130 to 159 mg/dL is considered borderline high. But for Indians, particularly among those who have not had a heart episode yet, the range should be less than 100 mg/dL. With heart patients, that arc should come down to 70 mg/dL and those with recurrent heart attacks should keep it below 40 mg/dL.
WHAT DOES SMALL DENSITY LDL DO TO YOUR HEART?
When the circulating LDL volume goes high, it injures the endothelium, a thin membrane that lines the inside of the heart and blood vessels. These release substances that control cardiovascular relaxation and contraction as well as enzymes responsible for regulating blood clotting, immune function and platelet adhesion to the wall. When this is damaged, it encourages plaque deposition along the heart vessels and forms blockages.
WHY LDL CAN BE STUBBORN IN SOME
This is because the composition of a certain LDL is genetically predetermined. The liver takes away LDL from the blood through receptors that attach themselves to it. The higher the LDL receptors, the lesser their volume circulating in the blood. But in certain genetic disorders, such receptors are less and even absent. This condition is called familial hypercholesterolemia that leads to cholesterol accumulating in the bloodstream.
Your LDL range may swing out of proportion if, in your weight loss journey, you are following the high-fat, low carbohydrate diet. The excess fat can raise your cholesterol levels. On the contrary, a meta-analysis of 30 studies in May 2023, published in the European Heart Journal, found that vegan or plant diets can lower bad cholesterol by 20 per cent. Again, dietary intervention can be a supportive add-on to medication. Exercise is the third pillar to getting you back on course. Focus on cardio and aerobics as these have been proven to lower LDL and raise the good cholesterol or high-density lipoprotein (HDL).
Drinking alcohol can raise both cholesterol and triglycerides, which can contribute to weight gain. That’s why the American Heart Association (AHA) recommends that men have no more than two drinks a day and women have no more than one.
IDENTIFYING DENSE LDL AND TREATMENT
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The easiest way to understand what kind of LDL you have is to take the LDL sub-fraction test along with your lipid profile test. Your cardiologist will put you on statins. Anyone with diabetes over the age of 40 should take a statin, since high blood sugar levels greatly increase your risk of developing heart disease. Statins can reduce the risk of dying from heart disease among those with familial hypercholesterolemia by 76 per cent, says research.
For those who cannot tolerate statins over a long term, Bempedoic acid works by drawing out the plaque-forming LDL only from the liver, thereby not acting on muscles or causing muscle pains like statins do.
There is another category of medication that also can be used to help lower LDL called PCSK9 inhibitors, which is expensive, injectable and has to be taken every 15 days. In contrast Bempedoic Acid is an oral pill to be taken once a day and not very expensive. In extreme cases, Inclisiran injection is used once in six months to lower stubborn LDL. If you do have a resistant LDL problem, monitor its levels regularly — once in six months if you do not have a heart condition and once in three months if you do. All these therapies are easily available, and awareness is the key.
