Why do we hardly talk about cholesterol any more?

We have asked four doctors and the diagnosis is the same: cholesterol is still under strict surveillance and "is a challenge". Although we may feel that we no longer talk about it as much as we did 15 or 20 years ago, "it has never ceased to be an important cardiovascular risk factor," warns Ignacio Fernández Lozano, president of the Spanish Society of Cardiology (SEC). Is it more controlled? Yes, "because awareness has been raised, there are more effective drugs and current levels are more demanding: 116 mg/dl of so-called 'bad' cholesterol for the general population and limits of 70 for the population at risk and 55 in the case of very high risk".

Is it sufficiently controlled? No. "Although Spain is classified as a country with a low cardiovascular risk, a historical advantage attributed to the Mediterranean diet, in our country between 50 and 55 per cent of the adult population have total cholesterol levels above 200 mg/dl, which are considered high," warns Nuria Muñoz Rivas, a specialist in internal medicine and coordinator of the SEMI (Spanish Society of Internal Medicine) Vascular Risk working group. A starting point: "Cholesterol is modifiable with lifestyle and pharmacological treatment, which makes its control a key factor."

"Cholesterol is a type of fat that is necessary for many vital functions. It is in the composition of every cell in the body and is a precursor of, among other functions, vitamin D and various hormones. However, high cholesterol levels increase the risk of cardiovascular diseases or events, such as myocardial infarction or stroke, as well as increasing mortality," explains Miguel Ángel María Tablado, member of the Lipids and Cardiovascular Risk group of the Spanish Society of Endocrinology and Nutrition (SEEN).

"LDL cholesterol is known as 'bad' because it transports cholesterol to the arteries and favours the formation of atherosclerosis plaques. While HDL cholesterol is called 'good' because it participates in the reverse transport of cholesterol to the liver for elimination," says Dr Nuria Muñoz. However, "it is not a simple balance in which one compensates for the other. High HDL does not neutralise high LDL, and the main therapeutic objective is still to reduce LDL, as it is the causal factor most clearly related to cardiovascular events." The cardiologist agrees: "The risk is defined by the 'bad' one."

In assessing cardiovascular risk, it is not only cholesterol that counts. "Harmful habits such as smoking, overweight and obesity, impaired glucose levels (diabetes), chronic kidney disease, poorly controlled arterial hypertension and genetic factors also play a role," says the endocrinologist, who also points out the importance of regular exercise.

On the other hand, these risk factors, explains Dr Manuel Mozota, head of the Dyslipidaemia Working Group of the Spanish Society of General and Family Physicians (SEMG), interact in a peculiar way.

"They do not add up, but multiply the risk. In other words, if you have cholesterol and hypertension you have more risk than would result from adding the risk of both issues separately." One detail: "The risk depends not only on the specific cholesterol level you have at that moment, but also on the accumulated exposure to LDL over the years."

"Cholesterol does not hurt like osteoarthritis. That's why patients are not as rigorous about taking the drugs. They relax and, over time, they lose adherence," warns Mozota. And he points to studies that speak of "up to 40 per cent who do not comply with the treatment", normally "one pill a day, although there are treatments with injections".

"People think that cholesterol levels come from what you eat, but it doesn't depend solely on diet, which may have an influence of only 10 or 20 per cent," warns cardiologist Ignacio Fernández Lozano. "There are people who have a problem eliminating cholesterol, their body produces it in excess, or there is a genetic predisposition," notes endocrinologist Miguel Ángel María Tablado, pointing to some exceptions. In any case, what we eat does matter. "The worst fats are trans fats, found in industrial pastries, fast food fried items, snacks... The second ones to avoid are long-chain saturated fats (palm oil, coconut oil, or animal fats). For a heart-healthy profile, consumption of the latter should not exceed 9 or 10 per cent of total daily calories." As for beneficial fats, "the healthiest are monounsaturated fats (olive oil) and polyunsaturated fats (omega 3, omega 6, such as those found in fish or walnuts)."

A brief guide: "We should choose foods rated A or B in the Nutri-Score guide." Without even needing to check labels, "pulses, fruit, vegetables, eggs..." will help maintain a balanced diet. "Eating 'good' foods does not offset the 'bad' ones - there must be a substitution. That is, adding nuts to a diet rich in saturated fats will only increase calories and the risk of being overweight."