BRITISH BROADCASTING CORPORATION
RADIO SCIENCE UNIT
CHECK UP Programme No.Ìý4 - Cholesterol
RADIO 4
THURSDAY 13/12/07 1500-1530
PRESENTER: BARBARA MYERS
CONTRIBUTORS: JONATHAN MORRELL
PRODUCER: BETH EASTWOOD
NOT CHECKED AS BROADCAST
MYERS
Hello. More than three million people in this country have high cholesterol and are being treated with cholesterol lowering drugs such as statins. But what about those of us who don't know our cholesterol level, after all there are usually no obvious symptoms? But the fact is whether we know it or not a high cholesterol level - anything over five - puts us at increased risk of heart attack and stroke. And if you're already in a high risk category for these cardiovascular diseases you should be aiming for a cholesterol of four or lower.
Now there's quite a lot that we can do about lowering our cholesterol - diet and exercise can both help - but statins are what have really revolutionised medical treatment, as my expert today will vouch, he's Dr Jonathan Morrell, he's a GP who runs a special hospital clinic in cholesterol lowering.
We are really actually now, Jonathan, are we not getting on top of this whole cholesterol story?
MORRELL
Yes I think we are making progress. I think we've got to recognise cholesterol as the leading risk factor, particularly for coronary disease and to a lesser extent for stroke disease and we're talking about the biggest killers here in the UK, with 200,000 people dying every year from cardiovascular disease, we call it, chiefly heart attacks and strokes. And we know that cholesterol contributes about 60% of the risk to individuals dying from heart attack and about 40% of the risk to stroke. So it's an enormous problem - 70% of adults in the UK have raised cholesterol.
MYERS
So lowering it really will make a difference to overall levels of death and ....
MORRELL
Lowering it has conclusively proved - we may debate this over the next half an hour - but lowering cholesterol is good news.
MYERS
Let's make that our start point.
MORRELL
And high cholesterol is bad news.
MYERS
Okay, well Heather Purves joins us from Buckinghamshire, she, I think, is concerned about her level of cholesterol and what she might do about it. What is your level and what do you think - or what have you been advised to try Heather?
PURVES
Oh hello. My cholesterol level is 6.8, I have an HDL of 1.98 and I have a triglyceride of 1.4 but my LDL, which is the bad one, as we all know, is 4.3 and I have a ratio of 4.1 and - but my GP says with that ratio he doesn't feel the need to put me on statins.
MYERS
Right, Heather don't go any further because you've given us a lot of figures there to take on board and I think we'll try and sort of pick over those just a little bit. So let me put that over to Jonathan, just comment, if you will, on this 6.8 which in a way seems a little bit high but also - obviously Heather's gone into this in some detail and she knows a little bit about the good and the bad cholesterol - the LDL and the HDL - but for the rest of us just fill us in on what that ratio is all about.
MORRELL
Yes we're talking cholesterol numbers here and quite rightly Heather's put forward her cholesterol ratio and she has a reasonably high level of HDL cholesterol and what I don't know about Heather is how old she is.
PURVES
I'm 65.
MORRELL
Oh that's very helpful because this is the sort of profile that's actually very common in ladies over 50. By and large men have higher cholesterol in younger life but in later life it's the ladies who take over. And this sort of profile, particularly with a high level of the good cholesterol, which of course offsets the total cholesterol risk, is quite common.
MYERS
So this ratio again - just to be absolutely clear - I think of four, the relationship between the good - if I can call it that - the good cholesterol, the HDL, and the LDL - that's an important thing to know, as well as knowing your overall cholesterol level?
MORRELL
It's very important for assessing Heather's future risk of a heart attack or stroke. And the way we doctors do that is by comparing Heather's profile to thousands of other individuals who've contributed to an enormous database that we compare to. And what we need to do is factor in whether Heather's blood pressure is normal ...
PURVES
126 over 76.
MORRELL
Ooh that's lovely to hear and do you smoke Heather? Do you smoke Heather - that's ...?
PURVES
Not anymore.
MORRELL
... another major factor. So you have been a smoker until when?
PURVES
Until 17 years ago.
MORRELL
Well that's good because we would class you as still a smoker if it was the last five years.
PURVES
And I walk two miles at least every - four times a week.
MORRELL
Right, so what I'm doing now in my mind is envisaging you on some special charts that we use and I'm sure your GP has used because I agree with him that probably your risk is not that that you need to embark on medication for your treatment. Now that sounds rather odd but we must view cardiovascular disease - heart attacks and strokes - as not just being due to cholesterol, despite what I said earlier, it is a matrix - it's a jigsaw puzzle - of all the risk factors that we put together. And the chief risk factors are smoking and blood pressure and because they're low with you it makes less of your cholesterol risk factor.
MYERS
So in short and jumping a little bit to the chase because I'm aware of how many other people want to speak to us, Heather's clearly doing alright, doing the right sort of things and her doctor is right then to say statins wouldn't be necessary?
MORRELL
Yeah I suspect that this is correct. There might be some other reasons that would promote your risk - an adverse family history and we might talk about that in the course of the programme - but for Heather really it's a strong accent on healthy eating, physical activity and continuing to enjoy life.
MYERS
Thanks Heather. Flora wants to pick that up - she joins us from Essex and is interested to know what she can do, which is to say other than perhaps taking medication. Have you been advised to try to reduce your cholesterol Flora?
FLORA
Well I've only just found out in the last two months that it's 6.8 - just the same as the previous caller - but my blood pressure's higher than hers - mine is 155 ish over 83 and it's being monitored, I'm going back in a month for another blood pressure monitor but I want to avoid going on any medication really. I'm fairly active, I'm 65 and I weigh about 9 stone 10, I should think.
MYERS
So you feel you've got a window of opportunity here to do something to may be get it down so that when you go back the doctor will say oh you're fine?
FLORA
I'm not sure about the ratio of the LDL and the HDL with my cholesterol.
MYERS
Now that would be important and we've said that already, Jonathan to pick that up.
MORRELL
It may be a key influence here and again Heather have you been or are you a smoker? Sorry Flora.
FLORA
Sorry, have I been?
MORRELL
A smoker.
FLORA
No. Only when I was a student.
MORRELL
So forgive me but I would need to consult in detail these predictor charts but it sounds to me as if you might be the same as Heather, that we've just spoken to, and really to concentrate on lifestyle and certainly you ought to go through this assessment process with a healthcare professional, now that means your GP or a nurse in the practice, and this is something that we're doing everyday in general practice and this puts your cholesterol level in context.
MYERS
So what about that particular point of trying to actually lower it and if so you're to make a kind of dash to the finish and try and get something sorted within a very short space of time, is that even realistic?
MORRELL
Sure, sure. No it is realistic and it's something you should go for. The advice is quite detailed and complex and I can list them and I'll mention some of them in a second. We need you to look at the fat content of your diet - to try and have a lower fat diet - in particular try and avoid the pernicious nasty sort of fats like saturated fat - those hard white ones that we can't flush down the Sunday lunchtime sink - look at trans-fat contents within foods - this is where food labelling comes in so helpful. We need to think about other fats, we know the olive oil story, so called monounsaturates, we know about polyunsaturates in margarines and so on and these are good fats and healthy fats. We need you to try and avoid visible fat - cut it off meat, cook in a way that loses fat by steaming, grilling, allowing the fat to run away and so forth. Other attributes within the diet - low salt, sensible alcohol. And there are some special elements of eating such as Soya products and what we call plant sterols - natural vegetable forms of cholesterol that are cholesterol lowering and we can buy these now in the supermarkets in spreads and fats and so on.
MYERS
And I mean of course there's a lot of good dietary advice about and this sort of tallies with that, so that's perhaps not so difficult for people to get that kind of information but will it make the difference - how much can you realistically lower your cholesterol level, even if you do all that, council of perfection?
MORRELL
Well there's some very interesting research from Canada by a gentleman called David Jenkins and he put together a diet which he called Portfolio Diet. So this is a portfolio of cholesterol lowering approaches, particularly using Soya, these plant sterol compounds, that I've been talking about, and soluble fibre, which is a base ingredient within fibrous and vegetable produce that we take, all of which we know have a cholesterol lowering effect. If you add these together it's very interesting in people who stick to the diet - and I must say that's not always easy - but if you stick to this Portfolio Diet you can reduce the LDL - the nasty form of cholesterol - by about the same as a low dose statin drug and this is quite remarkable. In the past we've been used to advising diets that really were very difficult and didn't make much difference on an individual's cholesterol level but now we have this Portfolio approach, it really is catching on and I think we need to improve on the actual foodstuffs within the Portfolio approach and you can read about this in papers and on websites and there are more acceptable and tastier versions of the original research diet, which was pretty touch going I think for those that did it.
MYERS
Thank you for that. We've got an e-mail from Rita - and by the way good luck with that Flora and I hope that does do the trick, although of course if you do go on to statins I mean it's not - certainly not the end of the world and we can talk in more detail about what it means to be on statins for a length of time - but I wanted just to mention Rita's e-mail. She's got a cholesterol of 3.6, which she says is okay, and I guess that's right but she's saying is there such a thing as a low cholesterol, could her cholesterol level at 3.6 by low enough to be dangerous or are you just happy that it's 3.6 Jonathan?
MORRELL
I think when you consider that 70% of the UK are over five Rita's very lucky to have a cholesterol of 3.6 and she's very unlikely to run into a cardiovascular problem relating to her cholesterol.
MYERS
But do we need cholesterol of any particular level because it's quite important - I mean we make it in our own body, don't we, as well as ingesting it ...
MORRELL
We make cholesterol in every cell of the body, albeit chiefly in the liver, and it's a mandatory substance for us, it's a complex molecule but it's part of the cell wall of every single cell in our body. So without it we'd probably be a little puddle on the floor, so it's integral for life and it also makes vitamins, some of our hormones - in particular our sex hormones - so we'd be nowhere without the cholesterol. And it also makes bile acids, which are helpful in our digestive processes. So it's a tremendously important chemical. When we're born we have a level of cholesterol of between one and a half and two, so it's very low and from that we can grow a whole human being with a complex brain and nerve system and so on. So it's a vital substance. The trouble is in the UK we just have too much of it and we have vastly in excess of requirements, it swims around in the bloodstream, gets chemically altered and integrated into the walls of arteries and lo and behold the damage ensues, not immediately but after 40-50 years of a cruel - sudden events damage families in crisis situations and so on.
MYERS
Well let me take you on from there to Louise Kelleher, who's in Worcestershire, and is actually in this sort of position where the family has high cholesterol, so it's not even, I think, as though it's something that she has built up over a lifetime, am I right, you've got a condition known as hypercholesterolaemia.
KELLEHER
Yes familial hypercholesterolaemia.
MORRELL
Familial hypercholesterolaemia right.
MYERS
Okay, tell us the problem then for you Louise and for your family indeed.
KELLEHER
Well my family history is that my father died of a heart attack in his late 30s and as children we were all tested and I was diagnosed with the condition. So I was initially controlled on diet and then put on questran and later on statins, which reduced the levels a little bit but not massively. Then I came to have children, so I came off all the medication really and I just wondered in the present day with the NICE recommendations whether just having a raised cholesterol level is significant enough to mean that you should take medication or whether you need other risk factors as well really.
MORRELL
Right Louise you sound to be a young lady is it too rude of me to ask how old you are?
KELLEHER
No I'm 34.
MORRELL
Thirty four and you sound as if you've got little children in the background.
KELLEHER
I have yes a four year old and a one year old.
MORRELL
Well first of all you've been dealt an unlucky card. Familial hypercholesterolaemia - FH as we call it - is one of the commonest genetic abnormalities in the world and in the UK about 1 in 500 people have it. The trouble is that adds up to about 130,000 people around the country but we only actually know about a quarter of people like you. So in some ways you're unlucky but in other ways you're lucky that your family history pointed to a diagnosis and at a time in life that you can do something about it. And because it's a genetic condition and it's inherited 50/50 it's very important in time that you get your children checked because each child is a sort of toss of the coin as to whether they've inherited the same gene defect that you have. Now statins backbone of treatment for your condition, lifestyle definitely but it's not going to be enough to get your cholesterol low enough.
MYERS
And just for the record can I ask actually, Louise, how high your cholesterol level was?
KELLEHER
Well I mean I think I had it last tested probably about nine years ago when I wasn't on anything and it was around nine then, so it was very high.
MORRELL
Okay, most people with FH have levels over 7.5 and some very high into the teens. Louise, it's very important once you've finished your family - because we don't like to give statins to ladies of childbearing age who intend to have children - so once you've finished your family it's very important that you get on treatment because your risk - even if you're healthy in every other respect and particularly if you don't smoke and so on, which is a great risk factor for FH people, it's particularly important to save you from problems in the future. It's a rotten card that you've been dealt, you need support - statins you'll probably need in high dose and you may even need additional combination lipid lowering drugs - cholesterol lowering drugs - it may well be that you need one or two and probably need the advice, support and help, not just of your GP but also a hospital clinic. So the hospital clinic that I run in Hastings we have a lot of individuals like you and we see them on a regular basis and try and encourage screening for children, certainly around the age of five - they could begin to have a test and I would recommend that and of course half your children won't have it and half your children will have it, I hope none of them end up having it.
MYERS
So is the time right then, Louise, or are you thinking about having another child?
KELLEHER
No I think I've probably had - I've probably had - my twos probably are all I'm going to have I think probably.
MORRELL
All this risk assessment and the charts does not apply to you Louise and there are some other genetic conditions out there, as well as FH, and the charts do not apply to extremes of cholesterol with very high values.
MYERS
Thanks for the call Louise ...
MORRELL
Can I just mention one other important thing is that Louise you ought to know about the charity - Heart UK - which is the cholesterol charity and especially designed to help people with high cholesterol and I believe that details are going to be posted on the website.
MYERS
Indeed, you can follow that through, there'll be more information at the end of the programme about getting that. It's oh very nearly 20 past three, this is Check Up, I'm Barbara Myers and I'm talking today to Dr Jonathan Morrell, we're talking about cholesterol. And our next caller is on the line: Alain is in Bath and is interested in the side effects, I think, of statins, is that because you're taking statins Alain?
ALAIN
I was prescribed Simvastatin, which I believe is the cheapest version of it and I had horrendous side effects from taking it. I was put on it because I had a cholesterol level of 8.7, which is pretty high, and when I went back to the doctor about the pains I was getting in my arm and leg muscles, which started about two weeks after I started on the drug, I was told it wasn't that, it was something else. So I kept on with it and of course it got worse and worse and worse, I ended up being virtually crippled and in the end I came off the simvastatin myself. I've been back to the doctor probably every two weeks ever since that and in the end they took another blood test. My cholesterol was down to 6.8 but he said it wasn't the Simvastatin, it was other things I was doing. Now point is I think that before people are put on the statins they ought to be sat down and said look this is the possible problems you're going to get with them because although I stopped taking the Simvastatin two and half months ago I'm still on a full dose of Ibuprofen everyday to overcome the pains in my arms and legs.
MYERS
Okay Alain, let me put that to Jonathan, I'm sorry to hear that that's been the side effect and that you've perhaps not had that much sympathetic response from your doctor which seems a bit harsh. What would you say Jonathan about these side effects - muscle aches and pains?
MORRELL
Okay well there are some very complex issues that you've raised here Alain and the first issue obviously is that you do have quite a high cholesterol at 8.7 and I won't go over the need for risk assessment and knowing whether you need the statin or not, I'll assume that your GP has got it right and that you do need treatment. Although it's gratifying to see it's come down to 6.8. I entirely agree with you that everybody who starts a statin should have the warning that it is possible that statins could have a side effect for you and the chief side effects that we see are minor tummy upset, feeling a bit sick, occasionally diarrhoea, usually that's transient and sticking with the drug and it passes. Now that's pretty uncommon. Muscle side effects are the most common. If we look in clinical trials, though, there's very little excess of side effect in terms of muscle side effects compared to people who are not taking statins. But in clinical practice it does seem to be more common. And anything up to perhaps 20% of people on statins may complain. You've got to subtract from that the natural background noise of aches and pains that we have in older life, so I don't take a statin, thankfully I don't need one, but I still get up most mornings I've got aches and pains beginning to come on in my body.
MYERS
Can I just ask whether it might be the actual particular variety of statin and would your recommendation be to try another statin, if in fact you had some of these side effects?
MORRELL
Yeah that's a good thought, there are five statins available in the UK, I think Simvastatin - you mentioned that it's cheap - it is still a marvellous drug, it's a moderately potent statin known to - one of the few life saving and life improving drugs that we have available and statins, as a whole, taken by a 100 million people round the world.
MYERS
So in short we shouldn't be putting people off with the idea they might have this side effect?
MORRELL
You wouldn't get a hundred million people taking a statin if it was a very dirty drug with a lot of side effects. But for some people there are muscular side effects and all I want to say is we can get round them. I mean there are other statins, there are other drugs and all sorts of tricks up the sleeve that your GP and even specialists will have to help you Alain.
MYERS
Okay, thanks very much for that call, we go to Barbara in Hull who's interested in - well the more lifestyle changes - dietary things, including low cholesterol spreads or cholesterol lowering spreads. Question Barbara?
BARBARA
Well basically I was diagnosed at 6.8 ...
MORRELL
That's a very popular number today.
BARBARA
Yes and basically I've managed to cut it down to 5.1 by diet, going on to semi-skimmed milk and whatever.
MORRELL
Fantastic.
BARBARA
And sorry to advertise but I also take a little Benecol every evening after my meal which apparently is supposed to lower the cholesterol because it's got these plant extracts in. So basically what I was trying to find out was can you actually overdose on these plant extracts because according to the information it says that that's enough for your daily amount to lower it.
MYERS
Okay let's see if we can get a quick answer to that - overdose on it or not?
MORRELL
No you can't, no, it'll stop having an effect but you just need about two grams a day which is - if you're using spread enough to put on a couple of pieces of bread and butter, quite thickly though and you need to follow the instructions to get the right dose. But they are effective and they will lower cholesterol by around 10%.
MYERS
Okay that's helpful to know. I just wanted to squeeze in a last call from Mr Langham, very quickly Mr Langham your question for our expert today.
LANGHAM
Well thank you very much. It's just basically that in my mid-50s obviously I needed cholesterol lowering treatment and I didn't take too well to the statin treatment. Different statins were tried but when I got to the higher dose I did seem to get those side effects. However, I think I was just about over seven as a total cholesterol, don't know what the breakdown was, then my GP took me back on to a lower statin dose but also gave me another tablet and just basically rather quickly the tablet has brought my cholesterol down to just below four, I can't remember the exact measurement.
MORRELL
This sounds really good treatment and my guess is that that other tablet is Ezetimibe? Which is ...
LANGHAM
Is that how you pronounce it?
MORRELL
Yeah very difficult to pronounce but very effective. Ezetimibe is the right way and added to your statin does facilitate taking a lower dose, which might prevent you getting the minor statin side effects. So a highly effective therapy. Our only slight problem with it is we don't have the same trial basis to tell us that it's quite as safe and effective as statins in the long term but we have no reason to doubt that and I thoroughly endorse your GP, sounds quite a switched on doctor.
MYERS
And there we must leave it. Thank you very much our switched on expert today was Dr Jonathan Morrell. Thanks to everyone who's phoned and e-mailed. More on our free and confidential helpline, the number is 0800 044 044, you can go to our website of course where you can listen again or you can download the programme as podcast.
Join me again next week, if you will, we'll be taking your calls about problems of the hand. That'll be at the slightly later time of 3.15.
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