Personalised Management of High Cholesterol

A balanced approach in the cholesterol ‘expert’ civil war.

There is currently a huge amount of confusion in the public space around high cholesterol and its effects on cardiovascular health. In fact, if we are honest, there is a ‘civil war’ between so-called cholesterol experts with exaggerated agendas from both in the media and online which is difficult for the public to decipher. Which perspective should we believe?

Camp 1

The historical and usually mainstream academic and medical community, backed by large-scale industry-sponsored clinical research trials, believe and argue that the link between high cholesterol and cardiovascular disease (including angina, heart attacks and strokes) is fundamental.

As a result, current UK guidelines place cholesterol as the biggest risk factor for heart attack. This means that the population-based risk calculators (Q risk) used by doctors are heavily weighted towards your cholesterol measurements. If your 10-year risk of a cardiovascular event is over 10% (which it is for many simply as a statistical consequence of aging) then statin therapy is recommended as ‘primary prevention’, i.e. to prevent a future heart attack or stroke.

With 60% of adults over the threshold that would be defined as normal cholesterol in these guidelines, the majority require statin treatment. This camp are pro-statin and some have suggested that the benefits are so significant (and downsides / side effects so minor) that it should be supplemented in tap water.

Camp 2

The opposing camp come from a variety of backgrounds and include doctors, researchers, investigative journalists and alternative therapists. This group argue passionately that cholesterol is a fundamental physiological requirement for a well-functioning mind and body and that there is no or very little link between ‘high cholesterol’ parse and cardiovascular health problems or benefit from statins.

They suggest that the evidence has been manipulated by industry and conflict, highlighting the fact that Atorvastatin is the biggest mega-blockbuster drug of all time in terms of revenue generated for big pharma. Within this group there will be patient representatives who are convinced of long-term health problems affecting the brain, nervous system or muscles as a consequence of previous statin use.

The dietary perspective

The dietary perspectives further confuse the debate. The historical dogma that is still ingrained in most medical information, patient literature and advice is to go ‘low-fat’, eat high-fibre breakfast cereals and switch to margarine and Benecol to lower cholesterol. Despite this, you will be told that you can only expect to lower your cholesterol by around 10%.

The other camp tell you to eat fat (including from saturated animal sources) freely and are much more interested in sugar, refined carbohydrates and the consequences of insulin resistance which leads to type 2 diabetes and weight gain (usually around the belly).

There is a group of us (including me) who now listen objectively to both camps, and as with all things the truth is somewhere in the middle. The key is to not look at this from a general population perspective, but to use modern diagnostics to personalise the best treatment for the individual.

Cholesterol and statins

One of the things that attracts a lot of interest is my work around high cholesterol and statins. There is a lot of controversy currently around cholesterol, both within the general medical community and outside it. While the accepted wisdom is to take a statin to lower cholesterol, there are more people now suggesting that this approach is not correct, that the data has been misinterpreted and that we are actually overprescribing statins in this group.

While this ‘one-size-fits-all’ approach to the problem may at first glance appear to make treatment simpler, it doesn’t necessarily make it better. The reality is that the vast majority of people with isolated high cholesterol are being given population-based advice (i.e. to take a statin). They are not being given individual advice, which I believe misses a significant aspect of effective treatment.

Many people who come to see me with high cholesterol tell me that they would prefer not to have to take a statin, while others have experienced problems from medication. These people would then ordinarily find themselves caught in what is a bit of a vicious cycle, being told by a doctor that they need to take a statin, a medicine they do not want to take (or cannot tolerate), otherwise they risk having a heart attack.

As a doctor, I am passionate about the value of individual treatment pathways. What is the best treatment for one person may not necessarily be the best one for another. At Sulis Hospital Bath, we have the ability to ‘fine-tune’ management of high cholesterol for each individual, using medication, diet and lifestyle, and we see some quite remarkable results.

For this group of people, we use advanced non-invasive imaging techniques (including CT coronary calcium scoring and angiography) to help determine their individual risks and the best options for them to safely, effectively and reliably lower their cholesterol (or indeed not to worry about their cholesterol).

The vast majority of people that I see will typically have very high cholesterol, but no other cardiovascular risk factors. In the vast majority of cases, we can confidently tell them that they don’t need a statin, nor do they need to worry about their cholesterol profile. This is often a huge relief to people, as their cholesterol would otherwise be hanging over them in the future, causing anxiety every time they see their doctor. Rather than telling them they need to take a statin, we are able to give them closure on the subject.

Equally, there are people we can provide with robust data to suggest that they would, at a personalised level, benefit from pharmacological treatments and provide closure that they are doing the right thing on the balance of benefit and risk. This then becomes an informed, shared decision.

There is a third group (and we are very passionate about these patients) who do need to make a change but do not need to commit to tablet treatments. These patients can significantly improve their cholesterol profile (and associated risk factors) through prescribed and targeted dietary and lifestyle treatments.

(There is an urban myth in the medical community that you can only lower your cholesterol by 10% through dietary change. This is absolutely wrong. In an unselective population, you can expect to reduce it by at least 20%, and if you select the right patients, you can reduce it a lot further. Frankly, a lot of the information that’s out there at the moment about low-fat diets and avoiding saturated fat is historical. We provide people with a personal dietary approach based on current up-to-date evidence and thinking.)

This personal, tailored approach to the management of high cholesterol is transformative for so many of the people I see. We are able to give them a robust answer about whether or not they need to take a statin, or whether dietary and lifestyle changes will be sufficient.

It should be said of course that in some cases, the evidence and test data shows that somebody will benefit from taking a statin. In these cases, I have no hesitation in advising them of this. Again, it all comes down to a tailored approach. One size does not fit all for so many medical treatments, and this is certainly the case for the management of high cholesterol.

Tailored management for your high cholesterol

To learn more about how we can help manage your high cholesterol, please contact my PA, ‘Tash’ (Natasha Jones), on 01761 422287. Tash will be able to answer your questions and book an appointment for you at a time that is convenient to you.