How can we maintain healthy blood cholesterol levels in ‘rising Africa’?

The Rise and Rise of Cholesterol in Africa

November 2015 Issue

FREE

1

Africa is beginning to come into its own.

Economies are starting to attract external

investors. Infrastructure is being built and

construction is booming in many cities.

Connectivity is better than ever. Democracies

are maturing. Africa is rising... but so also are

medical conditions that can be associated with

an improved lifestyle, one of which is raised

blood cholesterol. Cholesterol occurs naturally

and plays a positive role in the body, however, at

high levels in the blood, cholesterol can cause a

narrowing of the blood vessels and increase the

risk of cardiovascular diseases. Cardiovascular

diseases can lead to a reduced life expectancy.

Wealth is only good if it brings a net positive

benefit to a person or group of people. If

Africans are to see the net positive benefit of

increasing wealth, careful attention has to be

paid to reducing the potential negative impact

that a wealthier life style can bring. Raised blood

cholesterol is one of those potential negative

aspects of a more affluent lifestyle. This issue

of First Class Health looks closely at cholesterol

and how to keep it low and healthy whilst Africa

continues to rise.

EDITOR’S PIECE

Keeping cholesterol down in rising Africa

Emmanuel OseEditor

Follow us @1stC1assHealth

Dr Gabriel OludareGabriel Oludare is a physiologist and university lecturer. He has an interest in the effects of food on the body.

Dr Melissa OwoajeMelissa Owoaje is a medical doctor with a particular interest in education and writing.

Emmanuel OseEmmanuel Ose is a pharmacist with experience in both hospital and community pharmacy.

Editors Piece - Keeping cholesterol down in rising Africa

Body of Evidence - The current picture of blood cholesterol in Africa

From the Doctors Office - Protecting your health by maintaining healthy blood cholesterol

Case Study

Food for Thought - Oats and the reduction of blood cholesterol

Myth Buster

Cholesterol Quiz

CONTENTS

1

3

5

7

8

9

10

3

The current picture of blood cholesterol in Africa

By Gabriel Oludare

BODY OF EVIDENCE

A global WHO report showed that raised cholesterol

is estimated to cause 2.6 million of all deaths (4.5%

of total deaths worldwide). Raised total cholesterol

is a major cause of heart disease and stroke in both

the developed and developing world. In 2008,

a global prevalence report showed that about

40% of adults had raised total cholesterol (raised

cholesterol is defined as levels ≥ 5.0mmol of total

cholesterol per litre of blood). The report showed

that, although the African region had a lower

prevalence of total cholesterol than Europe and the

Americas, the level of raised cholesterol was still

high enough to require some action. A more recent

review (2012) seemed to reveal a more worrying

picture. It showed that raised blood cholesterol was

highly prevalent in Black Africa at a rate currently

comparable with Caucasian figures. This more

recent review looked at the cholesterol picture

slightly differently. It focused on the important

components of total cholesterol, which are mainly

HDL-cholesterol (‘good’ cholesterol) and LDL-

cholesterol (‘bad’ cholesterol). The body needs less

‘bad cholesterol’ and more ‘good cholesterol’ to

have total cholesterol that is within the ‘safe zone’.

This increase in prevalence of raised cholesterol in

Africa might be due to the changes in lifestyle and

diet of Africans which is gradually evolving to the

diets of the Europeans and Americans.

40%

In 2008, a global prevalence report showed that about 40% of adults had raised

total cholesterol

Raised cholesterol is estimated to cause

2.6 million of all deaths

2.6m

4

The causes of raised blood cholesterol.

Blood cholesterol is considered to be raised if a

blood test shows that the level of total cholesterol

is ≥ 5.0mmol/l. The safe threshold for maximum

total cholesterol is lower if a person is considered

to be at risk of heart disease and other related

illnesses. Raised blood cholesterol is caused by

both genetic and environmental factors. Familial

hypercholesterolemia is a rare genetic disorder

characterized by very high LDL (‘bad’) cholesterol

and early cardiovascular diseases, which runs in

families. Environmental factors such as obesity and

dietary choices are another cause for raised blood

cholesterol. A diet high in saturated fat can increase

blood cholesterol levels. Other illnesses, such as

type 2 diabetes, obesity and hypothyroidism may

promote raised blood cholesterol.

There is a real cause for concern and immediate

action is needed to address the issue of raised

blood cholesterol in Africa. This is particularly so

due to the environmental factors that cause raised

blood cholesterol. Firstly, it is not unusual in Africa

to see foods rich in animal fat being consumed

at parties and weddings, in large quantities. These

kinds of food increase blood cholesterol which can

then begin to clog up blood vessels. In addition, as

wealth increases, waistlines seem to follow very

closely and as exercise is not part of most people’s

daily lives, a state of obesity is the inevitable final

destination. This can only create an environment

in which raised blood cholesterol will thrive.

Medical consequences of failing to address raised blood cholesterol.

Raised blood cholesterol is a major risk factor for

heart disease. Because raised blood cholesterol

generally has no symptoms, you can go on for

years without knowing you have it. The longer

it is left untreated, the greater the chance that

complications may occur. Possible complications

of high cholesterol include:

Atherosclerosis: Raised blood cholesterol can

lead to atherosclerosis; a dangerous build-up of

cholesterol and other fatty material on the walls

of arteries. These accumulations harden over time

and turn into plaque which can reduce blood flow

through the arteries or eventually block them

completely.

Coronary Artery Disease: Coronary artery

disease is the end result of atherosclerosis. The

coronary artery is the artery that supplies the

heart with oxygen and nutrients. The plaque

formed as a result of cholesterol and fatty material

accumulation permits less blood to flow through

the arteries, thus, the heart muscle cannot get the

blood and oxygen it needs. This can lead to chest

pain (angina) or a heart attack.

Heart Attack and Stroke: Most heart attacks

happen when a blood clot suddenly cuts off the

hearts’ blood supply causing permanent damage.

If the blood clot affects regions of the brain, such

that the blood supply to the brain is cut off, it can

lead to a stroke.

Peripheral Artery Disease: Peripheral Artery

Disease (PAD) develops when the extremities

(hands and legs) do not receive enough blood

flow. It is caused by blockage in the blood vessels

of the arms, legs, feet, or hands, and often signifies

atherosclerosis in other parts of the body. PAD

occurs most frequently in the legs. People with

PAD are at greater risk of heart attacks, strokes

and limb amputations.

REFERENCESFletcher, B., Berra, K., Ades, P., Braun, L.T., Burke, L.E., Durstine, J.L., Fair, J.M., Fletcher, G.F., Goff, D., Hayman, L.L., Hiatt, W.R., Miller, N.H., Krauss, R., Kris-Etherton, P. Stone, N, Wilterdink, J and Winston M (2005) Managing Abnormal Blood Lipids: A Collaborative Approach Circulation.112:3184-3209

Steyn K. (2007) The heart and stroke foundation South Africa: Heart disease in South Africa media data document pg 1-30.

Raal, F.J., Pilcher, G.J., Panz, V.R., van Deventer, H.E., Brice, B.C., Blom D.J. and Marais, A.D. (2011). Reduction in mortality in subjects with homozygous familial hypercholesterolemia associated with advances in lipid-lowering therapy. Circulation. 124:2202-2207

Oguejiofor, O.C. Onwukwe C.H., Odenigbo C.U. (2012). Dyslipidemia in Nigeria: Prevalence and pattern. Annals of African Medicine 11 (4) 197-202.

World Health Organization (2015) Raised Cholesterol: in Global Health Observatory Data (GHO) last accessed May 2nd 2015 @ http://www.who.int/gho/ncd/risk_factors/cholesterol_text/en/

5

High cholesterol and fat levels in the blood can

cause a narrowing of the arteries as well as

hardening of the arteries. These changes to the

arteries can restrict the flow of blood through

the arteries and cause health problems like

heart attack and stroke (broadly referred to

as cardiovascular disease). The 4 key types of

fat (aka lipids) in the body that we should be

aware of are (a) Low Density Lipoprotein (LDL)

also known as ‘bad’ cholesterol as it can cause

health problems if the levels in the body is high

(b) High Density Lipoprotein (HDL) also known

as ‘good’ cholesterol as it helps to remove and

dispose excess cholesterol from the body (c) Total

Cholesterol (TChol) which includes LDL, HDL and

other types of fat and (d) Triglycerides which refer

to the form in which the body transports the fat

that we eat.

Maintaining normal cholesterol levels in the blood

Several factors affect the level of cholesterol in the

blood. Some of these factors cannot be changed

while others can be changed. The factors that

cannot be changed include increasing age

(increase in age usually leads to higher levels of

cholesterol in the blood) and a history of raised

blood cholesterol in the family. Some people may

also have the genetic condition known as familial

hypercholesterolaemia.

It is important to consider the factors that can

be altered so that action can be taken to lower

cholesterol. These factors include eating too much

saturated fat, lack of exercise, smoking, excessive

alcohol intake and being overweight.

Important tests for cholesterol

There are 5 key measurements relating to

cholesterol levels in the blood. The 5 key

measurements are HDL (‘good’ cholesterol), LDL

(‘bad’ cholesterol), total cholesterol, triglycerides

and the ratio of total cholesterol to HDL. It is

important, particularly for people in the ‘at-

risk’ group (as described below), to maintain a

close watch on their cholesterol levels during

regular check-ups. As mentioned already, the

key principle is to maintain a high level of ‘good

cholesterol’, a low level of ‘bad cholesterol’ and to

keep total cholesterol and triglycerides low as well.

Cholesterol levels are measured by taking a blood

sample and the unit of measurement is millimoles

per litre (mmol/L) of blood. The table below

provides guidance on what normal cholesterol

levels should be.

Test Recommended levels (mmol/L)

HDL ('good cholesterol')

>1

LDL ('bad cholesterol')

≤3 (≤2 for the 'at risk' group)

Tchol (Total Cholesterol)

≤5 (≤4 for the 'at risk' group)

Triglycerides <1.7

Tchol/HDL <4

FROM THE DR’S OFFICE

Protecting your health by maintaining healthy blood cholesterol

By Melissa Owoaje and Emmanuel Ose

In principle, to be healthy, it is important to increase your levels of ‘good’ cholesterol (HDL) and reduce

your levels of ‘bad’ cholesterol (LDL), as well as keep total cholesterol and

triglycerides low.

6

BOOST YOURGOODCHOLESTEROL

REDUCE YOUR LEVELS OFBADCHOLESTEROL

REFERENCES 1. Henderson L, Gregory J, Irving K et al (2003). The National Diet and Nutrition Survey: Adults aged 19-64 years, volume 2: Energy, protein, carbohydrate, fat and alcohol intake. HMSO, London.

2. British Heart Foundation. HIS3 Reducing your blood cholesterol.

http://www.qrisk.org./index.php - for calculating CV risk

http://www.webmd.com/cholesterol-management/guide/understanding-numbers - types of cholesterol

http://www.patient.co.uk/health/Cardiovascular-Health-Risk-Assessment.htm CVD RISK ASSESSMENT

http://www.benecol.co.uk/cholesterol/understanding-your-number patient friendly info on cholesterol

http://www.nice.org.uk/guidance/cg181/chapter/key-priorities-for-implementation NICE guidance on managing cholesterol

http://www.nhs.uk/Conditions/Cholesterol/Pages/Diagnosis.aspx Diagnosiing raised blood cholesterol

Assessing the risk of cardiovascular disease

To prevent health problems like heart attack and

stroke it is important to know your level of risk and

carry out preventative action. The QRISK®2 risk

calculator http://www.qrisk.org./index.php can be

used to carry out a risk assessment.

The risk calculator takes a number of important

health factors into consideration and produces a

percentage that represents the chances of you

developing a cardiovascular disease in 10 years.

A 10% score means that 10 in 100 people with

the same risk factors will develop cardiovascular

disease in 10 years.

Immediate actions to take

It is always advisable to focus your energy on

things that are within your power to change.

For high blood cholesterol, the things that can

be changed to improve health include taking

up regular exercise to achieve a healthy weight,

replacing saturated fats (found in fatty meat,

biscuits and cakes etc.) with unsaturated fats

(found in oily fish, nuts and seeds), addressing

alcohol consumption and stopping smoking.

In addition, it will cost you nothing to take the

risk test found on this link http://www.qrisk.org./

index.php. If your risk, as determined by the risk

calculator, is greater than 10%, it is advisable to

speak with your doctor and seek to have a more

formal assessment done where a blood sample is

taken to find out your Total Cholesterol, HDL, non-

HDL and triglyceride levels. Your doctor can then

advice on the necessary actions to take based on

the results.

7

A 59-year old lady came to the doctor’s office. She

had a 5-year history of hypertension but no history

of heart disease, strokes or vascular disease. She

was not diabetic and had no family history of

heart disease. On examination her blood pressure

was high (150/95mmHg) and Body Mass Index (a

measure for determining appropriate weight) was

normal at 24. Her blood results showed that she

had a total cholesterol level of 6.2 mmol/L with a

LDL (‘bad’ cholesterol) level of 3.6 mmol/L and a

HDL (‘good’ cholesterol) level of 1.2 mmol/L. Her

triglyceride level was slightly raised.

The recommended total cholesterol level

is 5.0mmol/L or less for healthy adults and

4.0mmol/L or less for those at risk of heart disease

or stroke. The patient is considered ‘at risk’ as

she suffers from high blood pressure therefore

at 6.2mmol/L, her total cholesterol level is 2.2

mmol/L over the recommended level. In order

to reduce her cholesterol levels, the patient was

advised to commence a regular exercise program

and to follow a low fat diet. No medication was

prescribed at this point.

After 6 months of following a low fat diet with

regular exercise, the patient came in for a follow-

up examination and blood test. At this visit, the

patient’s total cholesterol had reduced from 6.2

mmol/L to 5.0mmol/L. The patient’s LDL had

reduced to 2.7mmol/L and HDL remained at

1.2mmol/L. The results showed a significantly

improved blood cholesterol level. Although her

total cholesterol is not below the recommended

level for ‘at risk’ patients just yet, there was an

improvement. The patient was advised to continue

the regular exercise and low fat diet.

CASE STUDY

8

Imagine yourself in the office one day when you

receive a call from a family friend you had not

seen for years. She happened to be in town and

was wondering whether you could provide a place

for her to stay while she attended to business in

your city for a few days. You were very happy to

accommodate her as you were keen to catch up

on happenings in her life and share developments

in your life. She stays for 2 days and you have a

great time catching up. On the third day, whilst you

are at work, you receive a text from her in which

she thanks you for your hospitality and says that

she has to catch a flight urgently. When you return

home, you find that she has made a very aromatic

pot of food. You take a spoonful of the food for

a quick ‘taster’ and you are very impressed. You

then sit down to enjoy the food with your family.

What thoughts will be going through your mind

as you enjoy this food?

The power in your oats

We already know that cholesterol has a ‘good’

(HDL) and ‘bad’ (LDL) component and to minimise

the risk of heart conditions we need to reduce the

bad cholesterol and keep the good cholesterol

high. The food we eat is one aspect of life and

an opportunity that is available on a daily basis to

address this balance of good and bad cholesterol.

There are a number of foods that have been found

to reduce bad cholesterol and one of those foods

is oats. Oats is a very well-known grain that is

eaten mainly as a breakfast cereal. Oats contain

a soluble fiber called beta-glucan. Beta-glucan

plays an important role in removing cholesterol

from the body. Bile acids bind to cholesterol in the

blood and beta-glucans increase the removal of

bile acids from the body. Therefore as bile acids

are excreted from the body, they take with them

the cholesterol that they are bound to and the

body has less cholesterol in the blood.

Over many years, studies in both animals and

humans have confirmed the role that oats play in

reducing cholesterol in the blood. Studies have

shown that oats can reduce both bad cholesterol

and total blood cholesterol, whilst preserving

good cholesterol. Other studies have shown that

oats go even further to increase the amount of

good cholesterol in the body as well as boost one

of its key components. What you have therefore

is a food that can reduce bad cholesterol and

increase good cholesterol in the body.

Size does matter

Information gathered from a number of studies

suggests that to enjoy the cholesterol-lowering

benefits of oats, the daily amount of oats to eat is

3x28g of oat meal. This is certainly not an unrealistic

amount of oats to consume daily. This amount of

oats should deliver the 3g of beta-glucan that

is needed to achieve a meaningful reduction in

blood cholesterol. Studies have shown that even

a small reduction in blood cholesterol, as small as

1%, can have some impact in reducing the risk of

heart disease.

Claiming the extra bonus

Going back to the story in the first paragraph,

I imagine that as you enjoy the wonderful meal

with your family, you may begin to think what a

blessing it has been to have such a surprise visit

from your friend. You would have accepted the

benefit of simply catching up after a long time

but the added benefit of a great meal is a very

welcome bonus to the family. I suppose oats can

play a similar role when it comes to food. You may

have settled to simply enjoy a nice meal but to

have a meal that not only provides energy but

also reduces cholesterol is certainly a meal worth

eating.

Referenceshttp://www.diabet-metabolism.com/article/S1262-3636(09)00008-1/abstract A Scientific Review of the Health Benefits of Oats by David Katz

FOOD FOR THOUGHT

Oats and the reduction of blood cholesterolBy Emmanuel Ose

9

Boost yourhealth with

good food

For Enquiries and Distributorship call: 0805 132 1155

10

Cholesterol only comes

from the foods you eat.

Food can only raise your

blood cholesterol.

Being vegetarian helps

lower cholesterol.

Raised blood cholesterol

can always be fixed by

lifestyle changes.

Eliminating red meat

and eggs from your diet

will completely address

the risk of raised blood

cholesterol.

In addition to food, the body naturally makes cholesterol on

its own. Cholesterol is useful in the production of new cells,

hormones (estrogen, testosterone and cortisol) and bile

production.

Some foods can help reduce your blood cholesterol. Foods rich

in fibre are one of such foods. The body uses cholesterol to

make bile and if bile levels are reduced, the body responds by

making more bile with available cholesterol thereby reducing

the level of cholesterol in the body. Dietary fibre acts by binding

to bile and inactivating it. The body then gets rid of the bound

bile and uses existing cholesterol to make more bile. This

process reduces the cholesterol in the body.

While avoiding the direct consumption of animal fats is good,

some vegetarian foods such as fried foods, potato chips, high

fat dairy products and shelf-stable sweets are high in saturated

(animal) fats which are known to increase blood cholesterol

levels.

Changes in lifestyle (e.g. exercise, healthy eating etc.) are

always useful in the reduction of blood cholesterol. However,

in cases where the level of cholesterol in the blood have not

been addressed by lifestyle changes or where genetic factors

are responsible for the raised levels of blood cholesterol, anti-

cholesterol medication may have to be added to lifestyle

changes to bring blood cholesterol down to healthier levels.

While red meat and eggs do contain some saturated fat and

cholesterol, it is not the biggest culprit behind high blood

cholesterol. It is perfectly healthy to consume eggs a few

times a week in addition to eating red meat once a week or

once every 2 weeks. Studies have found that foods containing

artificial fats (e.g. processed foods, fried foods, certain

confectionaries) can have higher fat content compared to foods

containing cholesterol naturally.

MYTH FACT

MYTH BUSTER

11

QUIZWhich blood lipid ratio is an important measurement for cholesterol

Triglycerides: HDL Total cholesterol: HDL

LDL: Triglycerides Triglycerides: Total Cholesterol

1Which lipids are known as good cholesterol?

Triglycerides HDL

LDL Total cholesterol

Raised blood cholesterol is considered to cause what percentage of global deaths every year?

10% 4.5% 8% 15%

Which of these illnesses does not promote raised blood cholesterol

Obesity Hypothyriodism

Stroke Diabetes

Which of these diseases is not a cardiovascular disease

Stroke Coronary Artery Disease

Peripheral Artery Disease Diabetes

What is the recommended level of ‘good’ cholesterol in the blood

>7mmol/L >5mmol/L >2mmol/L >1mmol/L

After taking the recommended risk assessment, what is the minimum percentage above which you are advised to speak with your doctor and get formal blood sample tests

10% 25% 17% 100%

2

3

4

5

6

7

QUIZ

12

Take the quiz online and get your result!

Have you enjoyed the magazine and would like to test your knowledge? You can

take the quiz online by going to our website (www.firstclass-health.com) and

clicking on the quiz button. You will get your results instantly on the website as

soon as you complete the quiz!

Get future editions sent to your email

Would you like to receive future editions of First Class Health? You

can subscribe to the magazine on our website and we will send you

future editions directly to your email. You can subscribe by going to

www.firstclass-health.com and clicking on the subscribe button.

Tell your friends about us

We would like to continue to provide First Class Health as a health resource

to anyone that wants it, anywhere, at anytime, free of charge to the reader.

Please follow us on twitter @1stC1assHealth and ask your friends and followers

to follows us as well. You can also find us on facebook by searching for First

Class Health. You will be the first to know when our next edition is published

and ready to be accessed for free.

Get answers to your questions

Have you read something in the magazine and have questions that you would

like to be answered? You can ask your question on our website by going to

www.firstclass-health.com and clicking on ‘ask the doctor’.

Readers response

Visit www.firstclass-health.com for

information on upcoming issuesFollow us @1stC1assHealth