While there have been ongoing conversations around high blood cholesterol and cholesterol management over the last few years, progress has been slow in tackling this health issue. According to HPB’s National Population Health Survey 2020,1 high blood cholesterol now holds the highest prevalence among the three chronic diseases – diabetes (9.5%), high blood pressure (35.5%), and high blood cholesterol (39.1%). On this front, there is more urgency needed around the conversation of cholesterol management in Singaporeans for them to understand why this is important.
by Dr Poh Kian Keong
Globally, cardiovascular diseases are the leading cause of death, killing almost 18 million people2 annually. This situation is equally grim at home, according to the Singapore Heart Foundation, 1 in 3 deaths3 were caused by cardiovascular diseases in 2021 and one of the main contributory factors to cardiovascular diseases is high blood cholesterol.4
High blood cholesterol is the most common form of chronic disease in Singapore, with 39.1%1 of the population being diagnosed with this condition and yet, awareness to manage the condition remains low. As there is no physical manifestation of symptoms, many do not see the urgency in managing their blood cholesterol levels and this is worrying as the risk factors of high blood cholesterol,5 which are physical inactivity, smoking, unhealthy diets, and obesity are similar to high blood pressure6 and diabetes.7 Individuals who do not detect early signs of high blood cholesterol and do not take tangible steps to control their blood cholesterol levels may end up being diagnosed with another chronic condition.
A trend is already seen in Singapore where a study8 done in 2019 showed that the proportion of individuals in Singapore aged 60 and above with three or more chronic diseases has doubled from 2009 to 2017.
The risk of contracting heart disease is increased by 2.3 times9 with high blood cholesterol and is multiplied by 3.5 times9 when an individual is diagnosed with two chronic conditions, such as high blood cholesterol and high blood pressure. The good news is that blood cholesterol is a modifiable risk factor10 and can be managed effectively with concrete steps taken in lifestyle changes. One of the most commonly known ways to manage the risk of high blood cholesterol is by reducing the consumption of bad fats,11 otherwise known as saturated fats and trans fats. It is important to strike a balance between foods rich in saturated fats, which are delicious foods such as fatty cuts of meat and deep-fried food, with a low-fat diet such as tuna and sardines for an excellent source of protein and Omega-3 fatty acids, as well as soluble fibre from fruits and vegetables.
With the easing of COVID-19 restrictions, we have also seen more gatherings in the past few months and such events may involve the consumption of alcohol. When we consume alcohol, it is broken down and rebuilt into triglycerides and cholesterol in the liver and as a result, raises the triglycerides and cholesterol levels in our blood.12 In such instances, it is recommended to always drink in moderation to manage our blood cholesterol levels. As a general guide,9 men should have no more than two standard drinks a day and women no more than one. A standard drink refers to either 220ml of beer, 100ml of wine, or 30ml of spirit.
When it comes to a healthier lifestyle to manage high blood cholesterol risk, one must not forget about their overall physical activities. The National Population Health Survey 2020 showed that 76.4% of Singapore residents aged 18 to 7413 had sufficient high and moderate physical activity, down from 80.1% in 2019 and 80.9% in 2017. The good news is that the survey also found 33.4% to be exercising regularly,13 which is an increase from 29.4% in 2017. However, segments of our population are also getting less physical activity as we are spending more time behind screens and being more sedentary. As a guideline, one should aim to have at least 150 to 300 minutes of moderate-intensity aerobic exercise each week and incorporate muscle and bone strengthening activities, such as weight training and Pilates at least two times per week.
However, where an individual has done everything their doctor has advised but is still unable to manage their blood cholesterol level. In this instance, the individual should speak to their doctor about the recommended treatments available. Medical treatments for high blood cholesterol can be found in both oral medications and injectables.11 Statins11 are the most commonly prescribed oral medication to lower blood cholesterol and are the first-line therapy for patients. These medicines work in the liver to prevent blood cholesterol from forming and reduce the amount of blood cholesterol circulating in the blood. Oral medications alone can lower cholesterol levels by 65% and can achieve 85% when used in conjunction with injectables.11 Currently, there are two classes of injectables available in Singapore, PCSK9 inhibitors and Inclisiran. The PCSK9 gene14 provides instructions for making a protein that helps regulate the amount of cholesterol in the bloodstream. PCSK9 inhibitors15 are monoclonal antibodies that target and inactivate the PCSK9 protein, which is made in the liver, and are administered once every two to four weeks. Inclisiran13 is one of the first of a completely new class of cholesterol-lowering injectables that targets a molecule called Messenger Ribonucleic Acid (mRNA). The mRNA consists of a “molecular blueprint” for producing the PCSK9 enzyme. Inclisiran helps to lower levels of PCSK9, which in turn boosts the liver’s ability to remove harmful blood cholesterol from the blood.
When it comes to high blood cholesterol risk in age groups, the prevalence of high blood cholesterol was found to increase with age,16 with around one in six adults in the 18 to 29 years age group to two in three in the 70 to 74 years age group. This calls for a need in the population to start managing their risk of high blood cholesterol as soon as possible through the adoption of a healthier lifestyle. Going for a 30-minute walk in replacement of catching up with an episode of drama and consuming lean meat with fruits and vegetables are all steps to paving the way to better heart health.
There is a need for the public to understand why cholesterol management is a critical issue as high blood cholesterol can rob our everyday lives away from us. If we do not act on this silent killer now, we can no longer look forward to the little things in life, such as enjoying a peaceful dinner on a Friday night after a hectic day at work. [APBN]
About the Author
Adjunct Professor Poh Kian Keong, Senior Consultant, Department of Cardiology, National University Heart Centre, Singapore
Adjunct Professor Poh is a Senior Consultant and Director of Research at the Department of Cardiology, National University Heart Centre, Singapore. He graduated with medical degrees from the University of Cambridge and was trained in the Massachusetts General Hospital and Harvard Medical School subsequently. He is a past President of the Singapore Cardiac Society, current Chair of the American College of Cardiology Assembly of International Governors and a member of the Board of Directors of the American Society of Echocardiography. His research interests include general cardiology, lipid disorders, ischaemic heart disease, heart failure, valvular heart disorders, and cardiac imaging.