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ACHIEVE YOUR TARGET CHOLESTEROL

Reduce your risk of heart disease

Heart is a stronger muscle that is about the size of our clenched fist (Texas Heart Institute, 2012).This ball of muscular beats approximately 100,000 times every day which is equivalent to over three billion heartbeats throughout on a normal life span (Texas Heart Institute, 2012). It is responsible for circulating approximately 3000 gallons of blood to the entire body (Texas Heart Institute, 2012). Coronary artery disease (CAD)is the major source of disability for people and most importantly CAD is the widespread cause of death (Shirazi, 2006). High cholesterol level in blood or hyperlipidaemia is one of the
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major reasons for CHD (American Heart Association [AHA], 2012). However hyperlipidaemia is modifiable and manageable risk factor (Kelly, 2010). This booklet will help to understand the importance of cholesterol maintenance and to lower the blood cholesterol level by healthy diet and exercise. This pamphlet can be distributed in inpatient and outpatient section, discharge pack of patients, private clinics, and cardiology departments in hospitals, pathologies, pharmacies and aged care. WHAT IS CORONARY HEART DISEASE (CHD) OR CORONARY ARTERY DISEASE (CAD) Heart needs continuous blood supply to perform its work appropriately (Cleeveland Clinic, 2011). Heart muscles receive blood by two blood vessels called right and left coronary arteries

(Patton). It is a hollow tube through which the blood can flow easily (Cleeveland Clinic, 2011). When there is too much of bad cholesterol travels in the blood, it gradually gets accumulated in the inner walls of the arteries that serve the heart (AHA, 2012). Other substances that flow through the blood such as proteins, calcium and cellular waste products attach to the vessel wall (Cleeveland Clinic, 2011). All these combine together and form a thick and hard deposit called plaque. Further Plaque can narrow down the arteries and limits blood flow to the heart muscle by actually blocking the artery. This process is called atherosclerosis (Cleeveland Clinic, 2011). A portion of the plaque may rupture and form a blood clot (Birtcher & Ballantyne, 2004). These blood clots may block or reduce the blood flow and oxygen supply to your heart, brain,
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and other part of your body (Birtcher & Ballantyne, 2004). If the blockage is considerable, you may possibly have a heart attack or stroke and a procedure may be performed on your heart to increase the blood supply to your heart muscle (Birtcher & Ballantyne, 2004). One of the best approaches to decrease your risk of having a heart attack or stroke is to control the increased cholesterol level in your blood (Birtcher & Ballantyne, 2004). Coronary artery disease starts at your young age and earlier in your teen years the blood vessel wall starts to show the deposit of fat (Cleeveland Clinic, 2011). There is no any cause for CAD, yet it has risk factors that escalate your likelihood of developing it (American heart Association, 2012). The major modifiable risk factors that cause CAD are hypertension, diabetes mellitus, hyperlipidaemia, smoking and obesity (Shirazi, 2006). Your body needs cholesterol to work appropriately. However, increase in cholesterol level gets
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accumulated your arteries and forms plaque (AHA, 2012). So as your blood cholesterol level rises, you are at high risk of acquiring CAD. Cholesterol level can be influenced by your age, gender, family history and food intake (AHA, 2012). WHAT IS CHOLESTEROL AND WHAT DOES IT CONTRIBUTE TO THE BLOOD VESSEL DISEASE? Cholesterol is fat like substance which is present in all the cells of your body (Birtcher & Ballantyne, 2004). Cholesterol gets mixed with protein to form lipoprotein so as to travel in the blood stream (Sviridov, 2011). Lipoproteins transport cholesterol to and from the vessel wall (Sviridov, 2011). Cholesterol can be obtained from two sources (Birtcher & Ballantyne, 2004). Firstly your body produces cholesterol and secondly you can acquire it in foods that come
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from animals such as meat, milk, egg or any food made from these products (Birtcher & Ballantyne, 2004). There are three types of lipoproteins commonly present are low density lipoproteins (LDL) or bad cholesterol, high density lipoproteins (HDL) or good cholesterol, and very low density lipoproteins (VLDL) (Birtcher & Ballantyne, 2004). Total cholesterol is formed by LDL, HDL and VLDL cholesterol and the required level of cholesterol is 200 milligrams per decilitre (mg/dL) (Birtcher & Ballantyne, 2004). LDL cholesterol usually forms 60 to 70 percentage of the total serum cholesterol (National Cholesterol Education Program [NCEP], 2002). This bad cholesterol gets sediment on the inner layer of the vessel wall and causes plaque formation. Thus increased level of LDL raises your risk of heart disease
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and stroke. An optimum level of LDL is less than 100 mg/dL (Birtcher & Ballantyne, 2004). HDL cholesterol or the good cholesterol normally presents at about 20 to 30 percentage in the total serum cholesterol (NCEP, 2002). Increased HDL level will decrease the risk of heart disease. Evidence states that it prevents the formation of atherosclerosis, however low level of HDL often indicates the risk of acquiring heart disease (NCEP, 2002). For men, HDL level less than 40 mg/dL is considered to be the risk factor for CVD. For women an HDL level less than 50 mg/dL is taken as this factor for CVD (Birtcher & Ballantyne, 2004). The VLDL is the triglyceride-rich lipoprotein and it is synthesised by the liver, which forms 10 to 15 percentage of the total serum cholesterol level (NCEP, 2002). Triglycerides are very common type of fat in your body (Birtcher &
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Ballantyne, 2004). Increased level of triglycerides is linked with low HDL cholesterol concentration. When triglycerides are greater than the normal level 150 or more, your risk of heart disease is increased (Birtcher & Ballantyne, 2004) HOW CAN I FIND OUT MY CHOLESTEROL LEVEL? Each and every person from the age of 20 years should assess the cholesterol level once in five years through a blood test called lipid profile (Birtcher & Ballantyne, 2004). This test will provide the level of total cholesterol, LDL, HDL, and triglycerides in blood which is measured in mg/dL (Birtcher & Ballantyne, 2004). Prior to the test an individual should not eat anything or fast for 9 to 12 hour for the lipid profile. But if the person didnt fast the needed amount
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of time prior to the test, the result will give the accurate level of total cholesterol and HDL (Birtcher & Ballantyne, 2004). But LDL, VLDL and triglycerides levels will be affected by the food that has been consumed before the test (Birtcher & Ballantyne, 2004). If laboratory results are high, doctor will be looking for another lipid profile with appropriate amount of fasting (Birtcher & Ballantyne, 2004) THE IMPORTANCE OF CHOLESTEROL: In recent evaluation it has shown that, high blood cholesterol level is accountable for 12% of death in Australia (National Cholesterol Education Program Australia [NCEPA], 2012).
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However blood cholesterol level is completely controllable, with a change in your diet and lifestyle. If everyone try to reduce the bad cholesterol (LDL) by 10% through dietary modifications, health professional believe that thousands of Australian lives could be saved every year (NCEPA, 2012). Cholesterol is important for your body, because it helps to make hormones and vitamin D. But a small amount is enough as it creates many health conditions (NCEPA, 2012). In Australia the average level of total blood cholesterol is 5.5 millimoles per litre (mmol/L), which is the highest level in the world. Furthermore 51% of Australians have high blood cholesterol than the recommended level (NCEPA, 2012)

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HOW LOW SHOULD MY CHLESTEROL BE? Each person should focus on reducing their LDL cholesterol level, which depends on their risk factors of heart disease (Scirica & Cannon, 2005). According to national guidelines suggestion, people with a history of heart disease, recorded atherosclerosis or having the risk factors like diabetes are under higher possibility of acquiring heart disease and they should target their LDL level less than 100 mg/dL (Scirica & Cannon, 2005). Moreover for those people who are at higher risk such as, individual with known heart disease and various risk factors mainly diabetes, continued smoking, or a recent heart attack, chest pian , they should have LDL less than 70 mg/dL (Scirica & Cannon, 2005).
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Further, persons without heart disease but have possibilities to obtain, as they have other risk aspects like hypertension, diabetes mellitus, smoking and family history of heart disease should target for LDL level less than 100 mg/dL (Scirica & Cannon, 2005). LIFE STYLE CHANGES TO LOWER CHOLESTEROL: Cholesterol level can be decresed by changing the lifestyle particularly in diet and exercise (Scirica & Cannon, 2005). Normally, individuals cholesterol consumption should be less than 200 mg per day and total fat intake should be around 20 to 25% of all calories (Scirica & Cannon, 2005). With an ideal diet and routine exercise one can reduce the total and LDL cholesterol by 10 to 15% (Scirica & Cannon, 2005).

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WAYS TO REDUCE BLOOD CHOLESTEROL LEVEL THROUGH DIET: UNHEALTHY FATS OR SATURATED FAT AND TRANS FATTY ACID: Saturated fat consumption will cause considerable increase in LDL cholesterol and thus it has been related to the risk of cardiovascular disease (Siri-Tarino, Sun, Hu, & Krauss, 2010). Saturated fats are solid and rigid in nature (Anderson,Young, & Roach, 2012). Saturated fats are found in various food especially from animal origin, such as fat in meat, butter, cheese, whole milk, cream, lard (Anderson,Young, & Roach, 2012). It is also found in some plan oriented food such as coconut oil, palm oil, cocoa butter in chocolate and in hydrogenated vegetable oil (Anderson, Young, & Roach, 2012). Saturated
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fats are found in deep fried items snack foods, biscuits and in all commercial cakes (NCEPA, 2012). Trans fatty acid has been evidenced to increase the LDL cholesterol level, which elevates he risk of acquiring heart disease (Anderson, Young, & Roach, 2012). However Trans fatty acid exist in only small amount of food in the Australian Diet (NCEP, 2012) ADD MORE HEALTHY FATS POLYUNSATURATED FAT AND MONOUNSATURATED FAT: Substituting saturated fat with polyunsaturated fat will effectively reduce Triglyceride and LDL level by decreasing the LDL cholesterol synthesis or by increasing the LDL clearance rate (Siri-Tarino, Sun, Hu, & Krauss, 2010). Even though this replacement of polyunsaturated fat evidence in decreasing HDL, it reduces LDL significantly (Siri-Tarino, Sun, Hu, & Krauss, 2010). Poly saturated fats are found plenty in sunflower oil, corn oil, soybean oil, cottonseed oil and sesame oil (Anderson, Young, & Roach, 2012). Similarly, replacing
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saturated fat to monounsaturated fat will also reduce total, LDL and HDL cholesterol level (Siri-Tarino, Sun, Hu, & Krauss, 2010). Monounsaturated fats are mainly found from plants such as olive oil, canola oil and peanut oil (Anderson, Young, & Roach, 2012). SOLUBLE FIBRE AND SOY PROTEIN: Diets high in soluble fibre have shown beneficial effects on decreasing serum cholesterol levels. Studies show that 10 to 30 grams of soluble fibre in a diet will reduce nearly 10 % in LDL cholesterol level (Rosenthal, 2000). Fibre works by binding with bile acids in the small intestine and thus reduces bile acid reusing (Rubin, 2011). This promotes liver to increase the cholesterol absorption, which

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will replace the bile acid supply resulting in reduction in serum total and LDL cholesterol without any change in HDL cholesterol and triglyceride (Rubin, 2011). Fibre rich food contents are oats, psyllium seed, guar gum and pectin. According to studies consumption of 9 to 16.5g/day of a soluble fibre mainly psyllium and guar will decrease serum total and LDL cholesterol levels of 5.5% to 11% and 3.2 % to 12.1 % respectively (Rubin, 2011). Soy protein is synthesised from soybeans. Soy protein rich food content includes tofu, tempeh, whole soybeans, soy yoghurt, soymilk, soynuts, and soycheese (Erdman, 2000). Soy based products helps in reducing LDL cholesterol level and triglyceride levels (Rosenthal, 2000). In evident to the studies substituting 2 serves of milk with soymilk and 1 serve of meat with tofu will decrease LDL and Triglyceride levels (Rosenthal, 2000). Soy based products are low in saturated fat and it is suggested to include in your diet frequently (NCEP).
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INCLUDE PLANT STEROL ENRICHED FOOD: Plant sterols exist naturally in small amounts in various plants like corn, soybeans and sunflower seeds (Rosenthal, 2000). Plant Sterol intake through soybean oil or pine tree oil is assisting to reduce blood cholesterol level (Lichtenstein & Deckelbaum, 2001). As plant sterols are poorly absorbed by human intestine, they reduce cholesterol level by affecting the absorption of cholesterol from the intestine to the body, thus resulting in decrease serum cholesterol level (Rosenthal, 2000). Its reported in studies that sterol decreases cholesterol absorption by 33% to 66% (Rosenthal, 2000). Plant sterol can be esterified in canola oil and added in the food contents like margarine and salad oil (Rosenthal, 2000).
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It has shown in studies that consumption of 2 to 4 g that is 2 to 3 servings a day of sterol reduces the total cholesterol by 10 % and the LDL cholesterol level by 14%, but the HDL and triglyceride level are not affected (Rosenthal, 2000). In evident from the studies that 1% drop in LDL level will reduce 2% risk of CAD. Sterols when included in the diet, it can give nearly 30% of decrease in the occurrence of CAD (Rosenthal, 2000). FISH OIL AND OMEGA 3 FATTY ACIDS: Omega - 3 fatty acids are extremely polyunsaturated and consumption of these fatty acids will help in reducing VLDL and triglycerides (Anderson, Young, & Roach, 2012). People with high VLDL level are more benefitted by Omega 3 Fatty acids as it reduces the level of VLDL in blood. It also decreases triglyceride by lowering the
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production of triglyceride from the liver (Rosenthal, 2000). Fish oil is considerably known for its benefit in reducing the lipid levels, also it significantly reduces excess level of triglycerides in blood occurring after a meal (Rosenthal, 2000). Consequently fish oil reduces the VLDL level with no alterations in HDL level and LDL level depends on the individual (Rosenthal, 2000). Consumption of 200 to 300 g week of fish or shellfish will prevent CAD. Omega 3 fatty acid rich fish are anchovies, herring, mackerel, sardines and salmon. Concentrated Omega 3 fish oils are commonly available, and 2 to 3g per day of 30% concentrate is recommended for people who dont eat fish. The doctor can suggest people according to their health condition

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EFFECT OF EXERCISE ON BLOOD CHOLESTEROL LEVEL: Generally dietary approach will reduce total cholesterol, LDL cholesterol and triglyceride levels and exercise results in increasing HDL cholesterol level. Combination of both low fat diet and exercise can enhance the process of blood cholesterol lowering (Kelly, 2010). Physical activity is considered to be important for cholesterols management and inactive lifestyle is one of the major risk factor for CAD (Shirazi, 2006). Reducing LDL level and total cholesterol level is essential to reduce the risk of CAD. Similarly increasing HDL is also important in reducing the risk of CAD. Since HDL cholesterol cardio protective, every 1 to 2 mg/dL rise of HDL is
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related to 2 to 3% decrease in CAD risk (Shirazi, 2006). According to the research conducted, physical activity has reduced total cholesterol by 40% and increased HDL by 16% for people with higher blood cholesterol level (Shirazi, 2006). Thus performing a routine physical activity will protect you from CAD by decreasing blood cholesterol and by increasing HDL regardless of LDL cholesterol level (Shirazi, 2006). CONCLUSION: Even though CAD is a preventable major cardiovascular condition; it needs significant care as it is responsible for considerable morbidity and mortality on the population. Though there are many risk elements associated, high blood cholesterol level is the foremost important risk for CAD. It is because as the cholesterol level

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increases people are in higher risk of CAD. Total cholesterol is made by LDL, HDL and VLDL. When there is an increased amount of LDL, the bad cholesterol or low level of HDL, the good cholesterol people are at higher risk range of acquiring CAD. LDL can be reduced and HDL can be increased by means of proper diet and regular exercise. Intake of food content with polyunsaturated fat and mono-saturated fat will help reducing LDL and VLDL. Moreover, adding fibre content food, soy based products, plant sterol rich food and omega-3 fatty acid will also help in reducing LDL level. Regular physical activity also effectively reduces total blood cholesterol level and increases HDL which will minimise the risk of CAD. Prevention is better and lot easier than cure, so when people understand that they can protect themselves from serious health issues; it reduces the causes of death.

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http://www.ext.colostate.edu/pubs/foodnut/09319.html Birtcher, K. K., & Ballantyne, C. M. (2004). Cardiology patient page. Measurement of cholesterol: A patient

perspective. Circulation, 110(11), e296-7. Cleeveland Clinic (2011, June). Disease and conditions. Cleeveland Clinic. Retrieved February 2013, from
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http://my.clevelandclinic.org/heart/disorders/cad/underst andingcad.aspx Erdman, J. W. (2000). Soy Protein and Cardiovascular Disease. American Heart Association Science Advisory, 102, 2555-2559. Kelly, B. R. (2010). Diet and exercise in the management of hyperlipidemia. Journal of the American Academy Family Physicians, 81(9), 1097-1102. Lichtenstein, A. H., & Deckelbaum, R. J. (2001). Stanol/Sterol EsterContaining Foods and Blood Cholesterol Levels. American Heart Association Science Advisory, 103, 1177-1179. National Cholesterol Education Program Austrailia (2012). Heart to Heart A simple guide to lower cholesterol through diet and lifestyle. Retrieved February 2013, from

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National Cholesterol Education Program (2002, September). Detection, Evaluation, and Treatment of High Blood

Cholesterol in Adults (Adult Treatment Panel III) Final Report. National Institutes of Health. Retrieved February 2013, from http://www.nhlbi.nih.gov/guidelines/cholesterol/atp3full.pdf Rosenthal, R. L. (2000). Effectiveness of altering serum cholesterol levels without drugs. proceedings Baylor

Universtiy, Medical Center, 13(4), 351-355. Rubin, R. C. (2011, February). Dietary Fiber New Insights on Health Benefits. Todays Dietitian, 13(2), 42. Scirica, B. M., & Cannon, C. P. (2005). Treatment of elevated cholesterol. circulation, 111(21), e360-e363. Shirazi, S. A. (2006). Effect of exercise on plasma cholesterol. Gomal Journal of Medical Sciences, 4(2), 70-73. Siri-tarino, P. W., Sun, Q., Hu, F. B., & Krauss, R. M. (2010). Saturated fatty acids and risk of coronary heart disease:
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modulation by replacement nutrients. Current Atherosclerosis Reports, 12(6), 384-90. Sviridov, D. (2011). Lipoproteins and Atherosclerosis. Baker IDI Heart and Diabetes Institute. Retrieved February 2013, from http://www.bakeridi.edu.au/research/lipoproteins_atherosclero sis/ Texas Heart Institute (2012). Heart anatomy. Texas Heart Institute. Retrieved February 2013, from http://www.texasheartinstitute.org/HIC/Anatomy/anatomy2.cfm

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