A quick guide to cholesterol

 Cholesterol helps to carry digested fat through our blood system to the cells where it id needed. But since fat and water do not mix (and blood is mostly water) our body needs to parcel up the cholesterol and other fats with soluble substances called lipoproteins. There are to types of lipoproteins: Low Density Lipoproteins (LDL: the bad cholesterol) and High Density Lipoproteins (HDL: the good cholesterol). The liver sends out the LDL’s with their load of cholesterol to distribute around our body. On their journey some of these LDL’s cal leave their cholesterol stuck along the walls of the blood vessels, making them narrower. If this happens in the blood vessels of the heart it can cause coronary artery disease. It is the job of the HDL’s to try and remove the “stuck” cholesterol and carry it back to the liver to be recycled or disposed of.

  Cholesterol lowering

A large body of evidence has demonstrated that cholesterol lowering reduces the risks of CHD events in patients with high cholesterol levels or a history of CHD.

The size of the reduction in CHD risk appears to be proportional to the size of the cholesterol reduction achived, such that reductions of about 1-1.5 mmol/ (40-60 mg/dl) produced by 3-hydroxy-3-methylglutariylcoenzime A reductase inhibitors (statins) reduce the risk of major CHD events by between a fifth and a third. 

In all adults aged 20 years or older, a fasting lipoprotein profile  (total cholesterol, LDL cholesterol, high-density lipoprotein (HDL) cholesterol, and triglyceride) should be obtained once every 5 years. If the test opportunity is non fasting, only the values for total cholesterol and HDL cholesterol should be usable. In such a case , if total cholesterol is ³ 200 mg/dl or HDL is < 40 mg/dl,  a follow-up lipoprotein profile is needed for appropriate management based on LDL.



Major risk factors that modify LDL goals

q       Cigarette smoking

q       Hypertension (blood pressure ³ 140/90 mmHg or on antihypertensive   medication)

q       HDL cholesterol <40 mg/dL. HDL cholesterol  ³  60 mg/dL counts as a negative risk factor and removes 1 risk factor from the total count

q       Family history of premature CHD (CHD in male first-degree relative < 55 years, CHD in female first-degree relative < 65 years)

q       Age (men   ³  45 years, women  ³  55 years)



LDL cholesterol goals and cut-points for therapeutic lifestyle changes (TLC) and drug therapy in different risk categories 

Risk category

LDL goal


LDL level

at which to initiate

TLC (mg/dL)

LDL level at which to consider

Drug therapy (mg/dL)

CDH or diabetes (10 years risk > 20%

< 100

³  100

³  130 (100-129 drug optional)

2+ risk factors

(10 year risk ≤ 20%)

< 130

³  130

10-year risk 10-20%: ³130

10-year risk< 10%:   ³ 160

0-1  risk factors

= 10-year risk < 10%

< 160

³  160

³  190 (160-189: LDL-lowering drug optional)



American Heart Association three phase approach to diet

The fase 1 is suggested to everybody. Fase 2 and 3 are suggested to people with cardiovascular disease.


Cholesterol management by diet


Cholesterol is a waxy, yellow-white substance produced mostly in the liver. One of its main jobs is to help to produce the substances we need to digest the fats that we eat (the bile acids). It is also needed by every cell in our body, it helps to insulate our nerves, make vitamin D, and to build some hormones such as sex ones. 

Cholesterol is found only in animal products. Plant foods (such as grains, fruits, vegetables, nuts) do not contain cholesterol. The cholesterol in foods we eat is dietary cholesterol. While the cholesterol in our blood come from two sources: the foods we eat and the body’s manufacturing process. The cholesterol we eat has much less effect on raising blood cholesterol levels than does saturated fat. With only a few exceptions, saturated fats and cholesterol occur in the same foods. The exceptions are egg yolks, organ meats, and shrimp (which are high in cholesterol but have only moderate amounts of saturated fat), and tropical oils (coconut, palm, palm kernel, and cocoa butter), which are high in saturated fat but have no cholesterol. Saturated fats (rich are: red meats and whole milk dairy products, including butter and cheese), are generally solid at room temperature. Polyunsaturated fats are generally liquid at room temperature. All vegetable oils except the tropical oils are generally high in polyunsaturated fats. Margarine is a vegetable oil that has been made solid by a process called hydrogenation, which makes it act like a saturated fat. It is suggested to choose a whipped tub margarine that lists a vegetable oil as its first gradient.


The yellow diet

For subjects with borderline high cholesterol (200-239 mg/dL) and no other risk factors. The diet is based on a maximum of 300 mg of cholesterol a day and no more than 35% of total calories from fat



To be used in moderation

To be avoided


Wholegrain bread and cereals, crisbread, porridge, pasta, matzo rice


Croissant, brioche

Milk  products

Skimmed milk, very low-fat yoghurt, very low-fat cheese (e.g. cottage cheeses, quark, fat-free fromage frais

Semi-skimmed milk, low-fat cheese (e.g. camembert, brie, feta, ricotta, low-fat yoghurt, Edam, Gouda)

Whole milk, full-fat yoghurt, full-fat cheese, imitation milk, condensed milk, cream


Egg white

Eggs yolks one weekly

Whole eggs, egg yolk

Vegetables, salads and fruits

All fresh or frozen vegetables, particularly legumes, dried beans, lentils, chick peas, sweetcorn, boiled or jacket potatoes, all fresh or dried fruit, tinned fruit (unsweetened)

Roast or chipped potatoes cooked in permitted oils

Roast or chipped potatoes, vegetables or rice fried in unsuitable oils or fats, oven chips, potato crisps, salted tinned vegetables


All white and oily fish (grilled, poached, smoked). Avoid skin!

Fish fried in suitable oils

Eel, roe, fish fried in unknown or unsuitable oils or fats



Mussels, scampi, lobster, oyster, scallops

Prawns, shrimps, calamari


Turkey, veal, game, rabbit, spring lamb, chicken (avoid skin!)

Very lean beef, ham, lamb, veal or chicken sausage, liver twice a month

Goose,  duck, usual sausage, all visibly fatty meats, meat pies, salamis, patès, bacon, poultry skin


Pepper, mustard, herbs, spices

Low-fat salad dressing

Cream, mayonnaise, added sat


Vegetable soups, consommés


Thickened soups, cream soups



Unsaturated oils e. g. olive, sunflower, corn, safflower,  walnut, soft (unhydrogenated) margarines based on those oils, expecially low-fat preads

Butter, lard, suet, dripping, palm oil, hard margarines, hydrogenated fats


Fruit salad

Sugar, jelly, marmalade, jelly, gelatine, pure sugar candy, sorbet, angel food cake, vanilla wafers, ginger snaps, meringues, puddings made with low-fat ingredients

Ice cream, puddings, dumplings, sauces made with cream or butter

Baked foods


Pastry, biscuits med with unsaturated margarine or oils

Commercial pastries, biscuits, pies, snacks



Marzipan, halva, nougat, boiled sweets, Turkish delight

Chocolate, fudge, toffees, coconut bars, butterscotch



Walnuts, almonds, chestnuts, hazelnuts, peanuts, pistachios, brazils

Cashews, coconut, salted nuts


Tea, mineral water, calorie-free soft drinks, filter or instant coffee

Alcohol, low-fat chocolate drinks

Irish coffee, chocolate drinks, full-fat malted drinks, boiled coffee


Herbs, spices, horseradish, Tabasco sauce, pickles, mustard, soy sauce

Salt ketchup, barbecue sauce, Worcesterschire sauce, relishes

Condiments or flavor aids made from fats and oils


The blue diet

For subjects with borderline high cholesterol plus two or more cardiac risk factors. This diet is based on a maximum of 200-250 milligrams of cholesterol a day, with no more than 25% of total calories from fats. If you are in the blue zone, use the yellow diet as a guide, but modify it as follows:

q       Limit consumption of red meat to four to six ounces a week

q       Avoid all egg yolks and products made with egg yolks

q       Use cheese and milk with no more than 1% fat


The green diet

For subjects with cholesterol > 240 mg/dL or higher. This diet is based on a maximum of 100 milligrams of cholesterol a day, with no more of 20% of calories from fat.

 Follow the guidelines for the blue diet and, in addition:

q       Eat only three ounces of poultry or fish per day

q       Consume mainly whole grains, legumes, vegetable and fruits

q       Avoid cheese

q       Use only skim milk


For subjects with high triglycerides

In addition to limiting dietary fats, avoid alcohol and simple sugars. These include:

q       Candy

q       Table sugar

q       Cakes, pies, cookies

q       Ice cream

q       Sugared soda

q       Fruit drinks, sugared gelatin

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