BHF Heart Matters Live: High cholesterol – how to lower it

Hello and welcome to Heart Matters Live. I'm Fergle McKini, head of BHF Northern Ireland. Heart Matters Live is BHF's free expertled Q& A series. Every 3 months, we bring you a live session where you'll hear from people with specialist knowledge, whether that's BHF funded researchers, clinicians, or people with lived experience, and you get a chance to ask them your questions. Each session is centered on a different heart or circulatory condition and today we're focusing on high cholesterol and how to lower it. High cholesterol is very common. In the UK around six in 10 adults have raised cholesterol levels. It often has no symptoms but over time high cholesterol can increase the risk of heart attacks and strokes. In just a moment I'll be introducing our speakers. There'll be a Q& A session at the end. So, if you have any questions for our speakers today, please submit them via the Q& A function throughout the talks. A quick note to say, if you have personal questions about your own health, please contact our heart helpline and speak directly to one of our cardiac nurses. Details of how to get in touch will be shared in the chat. During this session, please only submit questions that are directly for our speakers or related to cholesterol. Thank you. Today, we'll be hearing from Dr. Christopher Wall. Chris is a cardiology registar who completed a BHF funded PhD at the University of Cambridge. He's going to help explain what cholesterol is, why it matters, and give us a glimpse into his research into why some people may respond better to cholesterol-lowering drugs than others. Later in the session, I'll also be putting questions to Dell Stanford, BHF's very own senior cardiac diet dietician. Dell will be sharing some practical everyday tips that can help lower cholesterol. Now, our first speaker today was going to be Paloma. Unfortunately, Paloma isn't able to join us on the call. H she planned to share her experience of discovering she had high cholesterol and the small consistent changes she made to bring it down and improve our heart health. As we said, Paloma couldn't join us on the day of the live broadcast, but we recorded this interview with Paloma to include in the YouTube version. — Hi Paloma, thank you so much for being here. I know you haven't been too well, so thank you so much for uh recording this interview for our Heart Matters Live audience today. Um, to start us off, could you tell us a little bit about yourself and what life looked like for you before you discovered you had high cholesterol? How did you see your health? — Hi Anna, first of all, thank you for giving me this opportunity to come and speak to you about this. I'm sorry for the um the last minute changes for the live events. So my life, so I was a full-time worker in a corporate office. I was into clinical research for 16 long years. um before I retain myself and I'm currently a yoga teacher. So I've got flexible ass to myself. I teach yoga. I have got up time for myself to breathe, to meditate and take care of myself. So yes, I used to work 37 hours a week and was not very mindful as I am now with my health and diet and exercise like a very busy um professional mom of two young boys. Yeah. So, that was life like before I uh resigned from my full-time job and got into paying more attention to health and well-being, diet, and family. — Fabulous. And so, you found out that you had high cholesterol almost by accident. Um, can you talk us through how you got that news? — Sure. So it was back in November 2023 when I had participated in a future health study where they were collecting data basic medical data like blood pressure uh cholesterol HBM1C the marker for diabetes. They did a prick test for my cholesterol which showed the results straight away that I had really high cholesterol. um all the parameters the total cholesterol the triglycerides the LDL which is the bad cholesterol and my HDL which is the good cholesterol was low which should have been high or which is high which is good if it's high so that's how I accidentally found out um uh because I was otherwise a healthy person I mean my BMI my weight um my HBA1C which I used to get regularly tested because of for my family history of diabetes. They were all good. So I

looked and I felt healthy till I accidentally found out that I was living with such high cholesterol. Yeah. — And like you said, you were already living a lifestyle that many would consider healthy. So um what was going through your mind when you were told that this cholesterol was higher than expected? And I know the fact that your husband also got tested. — Yeah. So yeah that's the funny thing you know man because we this the closest adults that I live with shares has the same diet and her lifestyle more or less and uh he also participated in the same test where everything came under his cholesterol was like good as gold so it did it did come as a shock as in uh because by then November 2023 it was few months after I already stopped working I stopped working full-time April 23 so by then I had already started making changes is becoming more healthier in terms of food choices, cooking more at home than taking um eating takeouts or meals outside. So it did come as a surp as a unpleasant surprise shock to see oh well after doing so much you can still have something which is not right for you. So that definitely was a I would I see it as a good point to be more um to be looking at my diet, my lifestyle more carefully than I would if I did not go into this trial and um it was almost a random thing and I thought okay maybe yeah why not kind of a thing going there. So uh it did feel rotten at the first instance. I mean in the first sentence I was like no not me. So yeah — and I know that um you decided to speak to your GP after finding out um why don't you talk us through how you were prescribed on statins and sort of the next step that you took after that. — Yes. So of course with the very high cholesterol I think it was more than five. My total cholesterol was almost six uh which was very high. So I went I contacted my GP straight away to see um the way forward for me. Couldn't sleep over it. Definitely not. Um so I contacted the GP over electronic consultation form which is the quickest and the fastest way here in our um Jeep surgery to reach out and I got a response really quickly on the same day in a text saying that I should start statins. So the prescription was sent to my pharmacy. Uh but something did not feel right for me to start on a lifestyle medication over a text. So I give them gave them a ring the next day saying that ask request thing if I could have a face-toface consultation with a GP um and discuss more in detail before I start a medicine and somebody to help me through looking at my diet because which I said I I thought it was healthy for me. Um so that happened really smoothly and very um I got an appointment really quickly at the next day or the day after uh to see a GP in person and had a detailed um actually a 30 minutes discussion not a quick 3 minute discussion with the GP. Yeah. So they've been very supportive. There isn't a time where I felt they were not paying attention too much because as I said my other parameters were all normal. So I went to the GP office and they did all my other they reviewed all my other parameters like BMI once again my recent HBO report took my weight over there another time. Um they also did a Q risk score. That's a cardiovascular risk score which tells you given all of these um uh parameters uh the risk of one getting heart attack in 10 years. So that came down that was low because of other things were in control apart from cholesterol and I was also given some more blood tests um like liver function tests to assess the right dose of statins for me and in the same discussion um the GP reviewed my diet uh with me what was my current diet and the in the same discussion I asked my GP um because um I know I was eating a lot of cheese and ghee and I was aware that they are high in saturated fats but not cognizant that could or couldn't foresee that could result in such high cholesterol inside me. So I requested after if we could have some time like a 6 months time maybe um to

uh modify my diet once again — take out all that is high in saturated fats and then retest in 6 months before I start statins. — Mhm. Because in those two days as I said because I felt rotten and because it came as a shock I did a lot of internet research to see the factors which um — can lead to high cholesterol things you can do to bring it down — either without or with medicines. Even with medicines doing the things that I have done like the diet and the lifestyle changes would always help to lower your cholesterol further down. Um so with all the research that I have done myself um I requested that if you could see the GP was in agreements given again I must stress on this point given my other parameters uh rest of everything was under control normal looked very healthy and nice and good so yeah so that's when she agreed with my 6 months plan and eventually my liftes came back and they were normal So with all of that, I plunged into the six months of um revamp. — I think it's great that you had that discussion with your GP and that really open conversation to say, you know, this isn't a conversation about statins or not statins. is can I have 6 months to see and it's measured and it's considered and you know you were aware that you know if you got to the end of that 6 months and things haven't changed you know you would have had to start statins um but you did make some changes — totally — and I would love to hear about what changes you made and what had the biggest impact for you — so the major change I made was to cut down on all highfat dairy saturated fats. Uh cheese I used to have reduced fat cheese but I cut down to I completely stopped. So it is not uh it is zero with the I went down to zero cheese ghee which is Indian um clarified nothing but clarified butter which is very common in Indian house in Indian cooking. It goes in every dish um even on you know chapati Indian bread. So you put a dollop of ki and chapati to make it feel softer, nicer, tastier everything — and ki in is considered is consider still considered a superfood but well it didn't work for me as a superfood at all. I only realized because I literally stopped zero ghee and saturated fat and cheese and I see a difference in my cholesterol alongside a little tweak in my exercise little um more increase on my exercise. So and also um I'll come to the exercise later. Going back to the diet, I also started looking at um the labels of any packet foods. I was not I wasn't eating any processed food as much as uh I mean not much at all but even if I did I would look to see the uh labels this the traffic light signals you know traffic lights you have there red orange and green I wasn't a meat eater at all I did not love meat as such but I used to love my occasional sausage rolls sausages I cut down on that as well completely on those six months I wouldn't touch any meat eat uh at all and u that's about diet for my exercise I used to swim three times a week 30 minutes each session but having my discussion with my GP and also having read um articles in the internet um it's uh it is recommended the it said that little bit of aerobic exercise more than your strength I used to do two times the strength and three times swimming but aerobic which helps in uh increasing your HDL and lowering your LDL. So I increase my swimming by 10 minutes each session. So from 30 minutes per day to 40 minutes. So overall of 30 minutes a week that I could increase of my cardio of my swimming. That's my preferred cardio exercise. — That's great. continued with my strength. Yeah, — it was just a little — just a small Yeah, not a management manageable. It doesn't feel overwhelming from 30 minutes to an hour. That is you're failing your setting yourself for a failure mentally at least even if you can make time for it. You know just the thought that you're going to be there for another 30 minutes whether I'll cope or not. I continued with my strength uh important to I mean

I always say it is uh like it or not you got to do your strength training — uh in some form and um my yoga um I breathing meditating pausing and resetting each day helps in reducing your stress as well. Mhm. I mean it is uh um unrealistic to say you live a life which has no stress. Whatever is a stress it is not a life then so you'll have each one of us have different kinds of stress. So just to do that 5 minutes of breathing at the end of the day or if I some days I can manage even in the afternoon just sit and breathe. It's not a nothing high-tech about you know medit sometimes if you think meditation it becomes it's a very heavy word like there's a technique or there is a way to do it's just simple five minutes of deep breathing that helps reduce stress. So yeah, — amazing. Really, really great changes that you made and just sort of like the perfect example of, you know, not buying off too much and doing it incrementally a little bit, adding a little bit and changing your lifestyle in a way that is manageable. Um, and so after those six months, you had another cholesterol test. — Yes. — So where did your cholesterol end up and sort of what was it like to get that result? Yeah, this was it was eclectic I would say ecstatic. So yeah, after six months went back to GP and um I got my cholesterol test they were all down. Um so my total cholesterol came down to something in fours so 4 something which is from six to four. My HDL came down. HDL is yeah my HDL came or LDL is a bad cholesterol which is good. So but my LDL came down and HDL went up a bit. — Uh triglycerides came down. So of course with that it felt ecstatic and with that I did not have to start statins but with the changes I did it really worked then and thereafter I have continue to test myself um annually um and I've been able to keep it down without having um yeah so to the acceptable range. Uh yeah it felt great. It felt great and it felt like your hard work has paid off. Well, — yeah, small changes add up. — Yeah. Yeah, they do. — Amazing. And um I guess finally to anybody who's watching who might have high cholesterol or just found out they've got high cholesterol, um what would be your piece of advice to them or any words of support? — Oh, well, I would say not to be heartbroken like me as I was because at the end of the six months, everything was doable. Everything was right. it's an art. But I would definitely say to um uh to pay attention to it, not to dismiss it to go to your GP, have a chat and see what's wrong or what you can change. If required, take statins, take medicines as advised by GP. And um having your diet uh having more home-cooked meals wherever possible is makes a huge difference. And honestly is to see to figure out yourself taking the time to yourself to see what it is which does not work for you works for me. As I said — key or meat or cheese didn't work for me but it worked for it did have any pro it did harm my husband's in the same manner. So it is re there is no one size fits all. So it is really down to your body. So it is you who have to figure out what in your diet or how much of your exercise can um you can do to help yourself with that. So yeah and I you know because I'm here I can say I'm here if you want to put this word out. Anyone wants to connect with me for a discussion for a chat for support uh through their journey of lowering cholesterol I'm here. Thank you so much and thank you Paloma for taking the time to chat us through that today. — Oh, no problem. It was a pleasure. — Now, next I'd like to introduce Dr. Christopher Wall. Chris is going to give us an insight into his research into treatment for high cholesterol. Welcome Chris. Over to you. — Hi, thank you very much for having me. Um I'm Chris Wall. I'm one of the doctors in uh in Advoc Hospital and in Cambridge and I did my research on cholesterol-lowering therapies and their effect on the firming up of arteries. And what I wanted to talk today about was about um our understanding of cholesterol and how cholesterol affects

the arteries. Um what effect that has on the heart itself and other ways in which other diseases can affect the firing up of those arteries. So to start with I wanted to talk about um really why are we so interested in um in this firming up process and uh when we talk about um this atherosclerosis or this firing up process the part that I'm really interested in as a cardiologist is the arteries that surround the heart. So um the heart is a pump and the arteries are very much like the power supply to the pump. Um, but what's very different about the heart is although you can kind of get away with unplugging your pump and it survives just fine. Um, when you have blockages to the supply of blood to the arteries of your heart, those that bit of living tissue essentially dies and that's what's called a heart attack. Um, and the same process happens in other organs. So it can also happen uh when the arteries in the neck f up and that can cause a stroke when they go off and block smaller arteries. And um and when those bits happen then that bits of muscle is essentially it dies and it's an irreversible process. So um downstream this can lead to problems like heart failure which is an enormous burden of health in the um as well as obviously a terrible disease. Um so what we're really interested in what my research is all about is about slowing down or reversing that firming up process. The role that cholesterol has in it and the role that other disease processes have in it. Um, so this is uh this is kind of a nice zoomed in view of what I'd call an atheroma. So um we often describe these as um like little fatty deposits that build up inside arteries, but really there's even more to it than that. Yes, there definitely is cholesterol in these um kind of bulges in the arterial wall, but there is also inflammatory cells. So this is things like white blood cells that you might typically think would fight infection as well as there might be very small bleeds into the artery as well as there might be even little bits of the artery that are kind of struggling to get blood themselves. And this can actually lead to a really complex uh structure to these plaques and um it's not so much the furry up of these plaques that is entirely the whole problem. Part of it is also the instability of this plaque. So, um I find the best way to think about it is like a blister and um and certainly uh part of a blisters lifestyle is the irritation that happens in maybe in your skin and that might cause a little ballooning but part of it is also about the thickness of the cap of that blister and also if there's been a if it's a blood blister and there's been bleeding into it or there's other processes. Um and really it's the rupture of that blister that causes the heart attack. So this is why it could be really confusing when we talk about um atheromomas because although we talk about a really chronic disease that slowly furs up arteries. Um really the events that happen are really acute. So a heart attack will happen in the course of well seconds to minutes as that blister bursts and a clot forms on the surface of it. This makes um diseasing the activity of this the disease and uh event prediction really difficult because it's a chronic disease that actually presents with really acute problems. Um and this is kind of what I wanted to highlight here. So um these blisters develop over many years. Some of them will stabilize and calcify and not cause any problems. Some will regress and some will rupture and they'll have a big clot that happens quite quickly and that can either be in the context of a stroke or heart attack. Uh both of which or either of which could be devastating. Um and then I wanted to talk about well some of the ways in which we can address this process. So um part of what causes this process is damage to the wall of the artery and then ingress of these of different types of cholesterols and This is why we separate the role of HDL and LDL cholesterol. So this is high density lip protein cholesterol and low density lip protein cholesterol. And one essentially is more involved in shuttling that cholesterol from the liver towards arterial walls and one is more involved in shuttling the other way. And so when we talk about having high cholesterol and low cholesterol, a lot of what we really mean is our ratio of low density lip protein cholesterol to high density lip protein cholesterol and the effect of those two. And I think uh Paloma's story really highlights that where um she started off with a very high LDL low density L protein cholesterol and low HDL uh cholesterol and then through her lifestyle modification her high density lip protein cholesterol actually went up and her low density L protein cholesterol went down and you can see that ratio is dramatically improved. Um and we have lots of ways that we can address this uh both in the context of diet and

lifestyle as well as in the context of medications. So um some of the ways that I'm sure most people who are watching this are aware of are statins um which have a beneficial effect on this ratio but there are also other and newer therapies that you can add in alongside that. So ineran which is one of the topics of my research as well as uh PCSK9 inhibitors all alter those ratios. And what I really want to highlight here is that um even if people do have problem well problems with statins or in any way reluctant there are actually lots of new novel therapies which um which can also have really good beneficial effects. So um so we shouldn't be having so there's lots that we can offer now that maybe we couldn't offer 101 15 years ago particularly in the way of enclosk inhibitors. Um and what I wanted to say here is the other aspect of my research kind of extends beyond cholesterol. Um but I think it's not um it's not fair to say that uh we've not already had an enormous effect. In fact um the rates of mortality from cardiovascular disease have dropped dramatically over the course of the last 50 to 60 years. Uh not all of this is mediated by cholesterol. Um but certainly it's not the killer it was 50 or 60 years ago which is uh really a reflection of the hard work from both a research and clinical perspective. Um there is still a lot to be done. It's still an enormous cause of um of mortality in the UK and abroad. Um but I do want to highlight that what we are doing does work. And um and so just to close off a bit of the arguments about cholesterol, um I do think that it's important to realize that um the body does need cholesterol to do some biological processes uh such as cell wall maintenance and hormone production. Um but actually low density lip protein cholesterol uh for most or most all patients can be safely significantly lowered. Um and even the therapies that I was talking about generally speaking would only cause a maximum sort of 50% reduction which leaves you with left plenty left to do any sort of biological processes. Um and uh low density lip protein cholesterol is one of the uh most wellestablished ways of reducing uh cardiovascular risk. So um so it is a really there's uh there's plenty of evidence to support that case. uh but I do want to talk about uh aspects of my research that go beyond that. So uh we do say that there's been a huge reduction in uh cardiovascular risk over the last 60 years, but there's stuff left to do and um and some of this is stuff we know about. So this is things like blood pressure lowering and uh diet and smoking modification and I'm pleased to see that uh some of the legislation around this is starting to change in the UK. Um but also the aspect that I'm really interested in is um kind of background inflammatory burden. So I was saying a lot that there were white blood cells inside those plaques that kind of react to the cholesterol and make these plaques more unstable and um and really to me this um this inflammatory process the central disease pro process that destabilizes these plaques and causes heart attacks and strokes. And so my research is really in the spectrum of how else can we could try and alter the inflammatory response uh to cholesterol and to other um and to other causes of atherosclerosis and um and firstly I want to say this is a challenging sort of job because um inflammation is both caused by this fing process as well as background inflammatory diseases predisposed to it. So um good examples are things like rheumatoid arthritis and autoimmune diseases uh which dramatically increase the risk of um of aththeroscotic disease as well as this fingering up process is kind of inflammation uh in and of itself. And so it can be quite difficult to underpin uh to detangle which one is which. Um but um I want to talk about a little some of the work I do to try and investigate that. Um and firstly why is this important? So um even despite optimal lowering of cholesterol and control of other risk factors uh it's estimated we could probably roughly half the residual cardiovascular burden. Um and that would still leave half it left. Uh so there's some really exciting work looking into some of the ways that we can um alter this background inflammation with things like cankinamab and cultureine. And um the aspect that I'm really interested in is actually trying to measure this as a an outcome for uh finding new drugs that can work uh using something called uh PET imaging. So using this type of imaging we can actually quantify the amount of inflammation that's going on in plaques and uh then we can see if drugs are working really quickly by seeing if this PET signal reduces. Um, so yeah, I think

that's everything I wanted to talk to you about today. And I hope what I've highlighted here is that cholesterol is certainly a significant part of modifiable risk, but there are other bits as well. And maybe this is why some people respond very well to cholesterol-lowering therapies if it's a significant portion of their risk burden as opposed to other people where they might have an inflammatory disease or they might have other life lifestyle factors that are contributing to their risk. Thank you, Chris. Uh, fascinating stuff. And now I'd like to introduce our third speaker, Dell Stanford, senior cardiac dietician here at BHF with 15 years experience supporting patients through NHS cardiac rehabilitation programs. Dell, uh, you've joined me on screen. I have some questions for you. Um, first of all, uh, what changes to overall diet would you recommend to help lower cholesterol? Uh thanks Fergle and also um thanks Diana for talking us through uh Paloma's uh case history like Paloma um an estimated 50% of adults in the UK have raised cholesterol and her story is a really great example of how it's possible to significantly lower your cholesterol level by changing your diet and increasing your physical activity levels. Um as we said Pal in Paloma's case she lowered her cholesterol by about 2 mill moles per liter. That's a reduction of 30%. Which is quite impressive and and not always that common actually. Um and she did this by cutting out ghee, which is clarified butter. Uh she restricted her intake of full fat cheese and pretty much cut that out as well. Um as well as um reducing her intake of sausage rolls, which I understand she had a pawn shop for. And uh al alongside that she restricted um she made sort of overall balance um changes to her diet to improve the balance of her diet. So the foods that we've talked about there are all examples of foods that are high in saturated fat. Um we know that eating too much saturated fat from foods like fatty meats, meat products, butter, cream, um pastries, biscuits, cakes, and processed foods can raise your cholesterol. However, it's not just animal fats um that are high in saturated fat. Coconut oils and palm oil which are frequently used in the manufacturer of processed foods are also high in saturated fat. And in fact, coconut oil is about 86% saturated fat, which is a third more than butter. So, the key issue here is to be replacing saturated fats with unsaturated fats in your diet. Where do unsaturated fats live? oil predominantly in foods like olive oil uh and vegetable oils. So that would be grape seed oil and sunflower oil and corn oil and the spreads that are made from those oils. Um unsaturated fats are also high in nuts and seeds. So that includes nut butters and oily fish and avocado. So practically what what does it look like if you're trying to make swaps and and um replace some of the saturated fat in your diet with unsaturated fat? So, it might mean using olive oil or vegetable oils for cooking rather than butter. Um, it might mean using fat spreads that are made from those oils um and in instead of butter as well. If you don't want to use fat spreads, which I know some people worry about fat spreads because technically they're ultrarocessed foods, then it would be a case of being a bit more creative and say using nut butters or avocado on toast and sandwiches. You know, it's about finding a filling for sandwiches, for example, that is um moist but not high in fat. So things like cottage cheese are quite good. Rather than having sort of tuna with um mayo and butter, you might have tuna mixed with cottage cheese and that gives you the moisture as well as the protein. So the other swap you might do is using um oily fish. So we're talking about sardines, piltchards, trout, mackerel, salmon um instead of um fatty meats and meat products. So um the simple this one of the most simple things you can do burgle is to replace uh the saturated fat in your diet, some of it with unsaturated fat. But there are a couple of other things um really important to increase your fiber intake. There are two types of fiber. There is um soluble fiber and insoluble fiber. Insoluble fiber is the roughage that is not digested and finds its way into your um large bowel where it very happily um feeds your gut bacteria which is a it's a very good thing. The other type of fiber is soluble fiber and that helps reduce the amount of cholesterol that your body absorbs. Unfortunately, only about 4% of adults in the UK um are eating enough fiber, which is 30 grams per day. Most of us eat about half that amount. So, a simple ways to eat more fiber include reducing the amount of

sort of white carbs you're eating, bread, rice, and pasta and that kind of stuff, and replacing them with whole wheat, whole meal bread, pasta, couscous, breakfast cereals, and whole grain rice. Another way of eating more fiber is to eat more pulses. We'll talk a bit more about those in a minute, but they're high in protein, they're high in fiber, but they're low in fat. Finally, for this question, um for Ferg, just eating more fruit and vegetables um at least five portions a day helps you to lower your cholesterol level. Choose from fresh or frozen or even canned. But if you're choosing canned uh fruit and veg, make sure they're canned in water and not brine. And if it's fruit, make sure it's canned in um natural juice rather than um sugar or syrup. Just before we go on, I just wanted to point out that the diet that I've just been talking about, high in unsaturated fats, oily fish, nuts, pulses, fruit and vegetables, is actually a Mediterranean style diet. Dr. Paul was just talking to us earlier about how chronic inflammation in the body plays a really key role in atherosclerosis. That's the furring up or the building up of fatty deposits in your arteries. There's really strong evidence that the Mediterranean style diet that I've just described has an anti-inflammatory effect um and can reduce your risk of heart disease by improving blood cholesterol amongst other things. In contrast to diets that are high in calories, processed meats, butters, sweets, sugary drinks, refined carbohydrates, those are linked to higher inflammation and an increased risk of coronary heart disease. And a lot of what you've been talking about there, Dale, is swapping out if you like going to other options. But are there particular individual foods that themselves will help lower cholesterol? — Yeah, thanks Fergle. Yeah, there are. I mean generally as dieticians we like to we prefer to look at people to change you know their diet as a whole because there is no one food that's a silver bullet that is going to make all the changes uh that you're looking for. However, having said that there are a few food most of which we've already mentioned that are particularly good at lowering cholesterol. The first one unsurprisingly is unsaturated fats. We've talked about those. So using olive oil and vegetable oils instead of saturated fats which might be ghee, butter, lard, duck fat, goose fat, coconut oil um or palm oil. Um really important to include unsaturated fats in our diet. The other um foods are oats and barley. Now u they contain a type of soluble fiber called betaglucan and this forms a gel in the gut which helps to stop the cholesterol from being absorbed um into the body and generally speaking if we eat about three grams of betaglucen per day. Uh that can help us to maintain our cholesterol levels. To give you an idea about what that actually means a 40 gram um portion of um oats or barley will give you about 1. 5 grams. So, one and a half grams of beta glucans. So, a couple of portion of those days that those um types of foods can help. Um the next uh group of foods which are really important again I've touched on them briefly is nuts. Nuts and seeds. They're a really good um source of unsaturated fat. They're high in fiber. They've got lots of other protective um chemicals um useful nutrients in them. And uh they're really filling and that's because they're high in protein. So, it's a really good swap for things like cakes and biscuits and chocolate um which are normally high in saturated fat. You don't need very many, just a handful. So, if you get a handful and you can't see them in your fist if you close your fingers around them, that's normally about 25 to 30 grams of nuts, which is useful. Don't be frightened though because when you buy nuts they are they do sometimes say that they're also high in saturated fat and that's just because they are very high in fat but it's predominantly unsaturated fat. Um the next food group that is really important are beans and lentils. Beans have had a real renaissance over recent years. They are such a good source of plant-based protein but they're very high in fiber especially soluble fiber. So, you can use those plant-based proteins to swap out um you know, red and and fatty processed meats. You'll still get your protein. You're going to get the fiber as well, and you're going to um get the soluble fiber, which helps to uh lower cholesterol levels. And the good thing about beans now is you don't have to soak them and boil them for hours. They're available in tins in water, and they're cooked. So, you literally just open them, give them a little rinse, put them in your soups, um uh salads, and put them in your stews. If you're making a chili conani, a simple technique would be to use double the amount of beans and half the amount of meat, and then you're automatically getting less saturated fat

and more fiber. Finally, but by no means least, we've said it before, fruit and vegetables. Really, we all just need to eat more, and most of us aren't eating five a day. So that is a very simple change that people can make to their diet to improve um to improve their cholesterol levels. — Thanks D. And what about foods that contain dietary cholesterol? Are these okay to eat? — Yeah, good question. So um we know about the cholesterol in our blood. What's slightly different type of cholesterol is the cholesterol in the food we eat and we tend to refer to that as dietary cholesterol. There are some foods that are relatively low in fat and saturated fat, but they're actually quite high in dietary cholesterol. And those foods include eggs. It's specifically the yolk, um, shellfish, so prawns, and things like liver. Um, and they're relatively high in dietary cholesterol, but not particularly high in fat, per se. when we eat those foods, they have a very limited small if any effect on your blood cholesterol. So, by and large, for most people, it's absolutely fine to have some eggs as part of a balanced diet um or shellfish or even liver as part of a balanced diet. Uh and it won't have a big impact on your blood cholesterol. Um that said um if you've been diagnosed with familial hyper cholesterolmia where your blood cholesterol is very high um and it's a sort of a family thing um you may be uh suggest it may be suggested to you to slightly reduce your cholesterol intake. So your dietary cholesterol but for most of us um that that's not required and things like eggs and prawns can be included as part of a healthy balanced diet. Okay, Dale, thanks very much indeed. We'll now bring back Chris uh for our audience Q& A session and uh you've already been popping your questions into the Q& A box. Uh and we'll go straight uh to those um first on the list and most folded. Is it possible to check cholesterol levels at home rather than bothering the NHS? And just feel free guys to pick a question if you want to answer it or both of you reflect on questions to or I'll spot one that's particular for you then I'll go to you first. But um — do you want to have a go at answering that one? — Yeah, sure. So, um I think there probably are private third party providers who could check your cholesterol. Though I would probably uh simply recommend that if you are concerned or you have a good reason to be concerned and the NHS is probably a reasonable first port of call. Um that uh there are some people who should be checked even if they are totally asymptomatic particularly if there's a very strong family history of high cholesterol. Um, uh, I probably would point people towards, uh, seeing their general practitioner as opposed to a third party, uh, commercial entity, even though I'm sure that they do exist. — Okay. And thank you for that question. Uh, next. I'm postmenopause and my cholesterol has gone up. How does menopause affect cholesterol? And if I go on statins, will I be on them for life? — I suppose uh there's two aspects here. Um there is the um will if I'm on statins will I be on them for life? Um and I think this is a really interesting question because um lowering cholesterol is really more of a marathon than a sprint. Uh it has an effect over a very long period of time and then causes very acute events. So it can be kind of a confusing one from that point of view. Um but certainly the benefit of being on a statin for a long period of time is that you then have a low cholesterol for a long period of time and that risk doesn't accumulate over that period of time. Um, and I just want to briefly go back to um to the point we were making on uh diet and other lifestyle modifications. And um and certainly as you get older, it's very preponderant that both your risk from your cholesterol goes higher as you get older as well as your other cardiovascular risks tend to increase. So, it's very common that when people type in a what's called a Q risk three score, which is predicts their 10year cardiovascular risk, at some point they're very likely to always benefit from statins indefinitely. But this is probably a good thing um because we reduce that risk over a really long period of time and then um and then their overall lifetime risk is quite a lot lower. Um and I think this is also relevant in terms of things that we can do transiently from a diet point of view or from other lifestyle point of view. So uh if it's primary prevention uh I generally would point people towards lifestyle modification is entirely

appropriate to bring down your cholesterol. um but setting reasonable timelines and milestones by which you can meet that and then timelines again to make sure you're still meeting that so that exactly as we said with paloma we're setting in measured uh interventions which can be longlasting um is really important. So I suppose my answer to that question is that the vast majority of patients who go on statins um will continue on statins but that is because we continue to offer quite a significant benefit to their cardiovascular risk over time. Um and uh if people do have problems on those statins there are other medications that people can have instead of statins. — Okay thank you. Um next question. If LDL is the bad cholesterol, why focus on total cholesterol when the HDL amount is seen as good? — I think LDL cholesterol is the most robustly studied. There are other cholesterols aside from HDL and LDL. There's VLDL uh cholesterol which also is a bad cholesterol. So um maybe that's why we consider them separately. another cause and high cholesterol can have other problems aside from its LDL component. So I consider them both useful metrics. Um and also it's kind of the way the blood test is done which is you get a total cholesterol a HDL and LDL in a ratio. So um yeah as well as a triglyceride level which has other effects aside from this. Um, so yeah, it's kind of the way the blood test is done, but uh LDL is probably most uh most pressing. — You illustrated this very well, Chris, in the graphic where you showed the cholesterol build up in the artery wall. And I think you did reflect on this, but there's a specific question. Is this happening silently for years without us realizing? And I wonder is the questioner actually just trying to put a timeline on that. Is this for years and years or an episode? — Uh yes. So it's certainly a process that happens for years and years. So in fact we can see the very start of these processes generally even in people in their 20s and 30s but they will experience the problems from it in their 50s 60s and 70s. So it takes a really long time. Um, and that being said, the actual progression, each individual plaque can have periods where it happens slightly more quickly and slightly slower, but as a whole body process, it takes a really long time. And um, sorry to answer that in a little bit of ambiguous way, but um, it's quite a difficult one to predict which plaques are going to progress quickly, which ones slowly, but certainly the overall disease is one of decades and not months. — Okay, thank you Dale. Uh, do I need to cut out certain foods completely? I think they're just saying completely here because the next is they're yearning for this or is it okay to eat certain foods every now and then or as a treat? — I think the simple answer to that is no. Um, as I say, you know, we want we're encouraging you to look at your diet as a whole. There's no one single food that needs to be banned or single food group that you should avoid. Um, obviously if you're generally having a low saturated fat diet with lots of vegetables and healthy plant proteins as well as lean meats and fish and you're maintaining a healthy weight, then having the odd um, you know, sweet treat or the odd savory I'm not going to mention sausage rolls again. I definitely don't want people to be eating lots of sausage rolls, but you know, if you're Yeah, you if it's an occasional thing, it's absolutely fine. And there is, you know, there is room for everything in a healthy balanced diet. It's just the quantity and the frequency that you eat in that is the issue. — Yeah. I don't know if they have this phrase over there, but here we talk about a wee bit of what you fancy? No. — You know, it doesn't do you any harm? H do foods marketed as marketed is you did touch on this, but it just reinforces through the question. Do foods marketed as cholesterol lowering actually work? — So, I think what you're referring to there, Fergle, is um plant steriles and stanols. So there are foods available that have been fortified um and there are different supermarket brands but the one most people would know would be benacle and it comes in forms of um yogurts and uh yogurt drinks and fat spreads. So um the the truth is that um on average if you're using those products the way that you're supposed to and having the correct dose they will generally lower your cholesterol level by about 10%. So they do work. There's a number of issues with that. Um and you can actually use them alongside statins as well to get your um cholesterol down because the way that they lower cholesterol is a different mechanism. So the two work together and they can work well with statins. Uh I think the issue are the

issues really are that it's expensive and you have to take them every day like statins and if you stop taking them the cholesterol will go back up again and um it's you know it's not always possible to do that. It is an outlay in terms of money and you're you know as we've seen with paloma it's possible to lower your cholesterol significantly without those. So, um I'm I'm, you know, yes, some people use them. Yes, they can be beneficial. Um but there are some kind of caveats to that and some people may find it difficult to use them every day. — Okay. Um thanks for that D. How often should cholesterol be checked with a family history of heart disease? This co questioner's father sadly passed at 49 of eskeemic heart disease. — Yes. So um in terms of uh in terms of checking of your cholesterol I think it's pragmatic to first get well it depends firstly if you are what we call primary prevention or secondary prevention and what I mean here is have you had problems with your arteries in the past or not and what this and the reason that I make a distinction between those two is because we set very different cut offs in how we treat cholesterol and how we treat your risk actually if you've had problems before And um before, we generally are uh we aim for actually much lower uh low density lip protein cholesterol levels than we would if you haven't had problems. Uh to the extent where the vast majority of patients would constitute benefiting from a lipid lowering therapy. Um, and generally speaking, if you're already on a lipid lowering, if once you're on a lipid lowering therapy, then measuring the effect of that something like 3 months after you started taking it would be pragmatic to see if there was any benefit from additional lipid lowering therapy. And then if not, then measuring it on a uh depending on how close you are to the next cutoff on something like a 12 month or two-year basis would be somewhat pragmatic. Um, that being said, if you're falling under the primary prevention arm, i. e. you haven't had problems before. It's just your father that's had problems. It actually depends on whether on quite how your father how your father's cholesterol is depending on whether or not you fall under being at risk of having one of these conditions which gives you a really high cholesterol. Um, and I think probably the right thing to do in this setting is if particularly if you're worried of having at least a one-off measurement to see where your cholesterol is at, which is something your GP could do. I know it's very high and they could consider looking into um either starting you on a therapy straight away or referring you to a lipid clinic if it's looking in that sort of ballpark. But um it really depends on what your dad's cholesterol was when that happened. and um and then also what your measurement is the first time it's done by your GP. So, it's very hard for me to give like really personalized advice. If your first measurement is kind of quite nice and low, there's probably not a need to repeat it in a short period of time. — Okay. Um this may have been touched on before, but I'll just honor the question. There are several cholesterol measures in total, LDL and HDL, along with ratios. which is critical the question is asking in determining lifestyle changes and or dietary and medication interventions. — Um so I think the two what I'd say is most modifiable and uh well studied are uh the amount of HDL the amount of LDL and then the ratio between the two. Um that's probably the most um yeah most robust and wellstied approach. uh there are other things that you can measure and we do that in a research world but uh from a clinical perspective I think that's where that's the most important bit — okay Dale what's your view on intermittent fasting um I sometimes says the question or fast for 16 hours could that help with cholesterol — um I don't think there's any evidence um that intermittent fasting helps with cholesterol um some people find it useful to um moderate their calorie intake by having uh sort of restricted eating patterns and restricted eating times. But there's certainly no evidence of that being something that you can reduce your cholesterol by intermittent fasting. If I just go back to what Chris was talking about just now though on contrary to that um there is evidence that eat replacing sort of saturated fats with unsaturated fats does improve your balance of LDL to HDL. So it can you can increase your HDL um by having a healthy balance of those fats um and reducing your saturated fat. But certainly no evidence that um intermittent fasting is going to benefit that. I mean weight loss generally

may have a positive outcome in terms of your cholesterol level. Um but I don't think it's really you know studied just to be looking at your cholesterol levels. Okay, this is a question related to alpha calcification. Is it why do we not test for calcification in this country as they do apparently in other countries and therefore how could we prevent calcification? — Yeah. So um it's a great question, really interesting question both in the way that uh the US varies from the UK in terms of our guidance for this and um I think what the question is alluding to is particularly measuring coronary calcification with a an CT calcium score to risk stratify patients. Uh which is probably most relevant in what we call the primary prevention cohort. And the reason I'd say this is because if you've already had a heart attack, we don't really need to measure your risk of having a heart attack. Your risk is high um because you've already had an event. Um what calcium scoring is really useful for is um if you're not quite sure whether or not someone is high risk or low risk and certainly there is evidence to support uh that it improves risk stratification over a Q- risk score. Um and um in terms of can we uh can it be used as a diagnostic tool to be able to distinguish who should be on statins and who shouldn't. I think on a case-byase basis there are very niche cases where it can be useful particularly for commencing some of the newer therapies uh which where risk stratification may be really valuable or if someone's really reluctant to have a uh or not sure where the risk is at and doesn't want to take a medication because they're not sure they're at high enough risk then risk stratification can be useful but for the vast majority of patients in fact the overwhelming majority a Q risk three is perfectly appropriate and uh a CT scan has additional radiation exposure associated with it. Um which is just not just doesn't add much on top of what we already have and exposes people to you know a significant amount well not a significant amount radiation but nonzero amount of radiation. Um so it's just not seen as beneficial albeit it does improve risk stratification a little bit. — Okay, maybe one for both of you. If you could give one piece of advice to someone worried about their cholesterol and heart risk, what would it be? Dale, maybe you kick off. — Yeah, I I'll mean I think it is um using Paloma as an example. She made changes to her diet that weren't vastly different to what she was doing before, but just small achievable maintainable changes. you know, swapping butter for vegetable oil when she was cooking and, you know, cutting down on um all fat cheetahs. Um so, I think what it is is have a look at your diet as a whole and to find two or three things that you think will be achievable for you and maintainable because it's no good going on a wacky diet that you know, yeah, you lose a load of weight and your cholesterol comes down, but you don't stay on it and it's not it's not sustainable. So think about things that are achievable for you and just making those swaps um will have a big impact. — Chris, any thoughts? — Um I'm afraid my answer is going to be very sim similar to Dallas actually. — That's okay. That just reinforces it. — I'll add a little bit of maybe a different uh lean on it, which is that um certainly cholesterol lowering is marathon, not a sprint. And um I think um and whichever option is opted for um be it medication or lifestyle or combination of both which would generally be more effective um it's important that it's maintainable and it's also monitored. So i. e. we make sure that we're continuing to make those modifications either taking our pills or making those lifestyle changes and if it's not working then escalating those treatments um so that we can actually keep people's risk really low and they can live a long and healthy life uh we do need to keep an eye on it to make sure those effects continue to happen. — Yeah. And I think there was one line uh out of Paloma's story I thought was very strong and sort of summed it up. Small things add up. So that you know sort of that focus uh around what you do. Um perhaps you've already touched on this Chris but just once again to honor the question is there anything to do to specifically address familial high cholesterol? — Uh yes yeah there certainly is and um and there are different treatments. Um if people have very high cholesterols then there are additional therapies that can be offered um on top of statins or in addition to statins or as an alternative to statins. Um I think that if people have familial hyper cholesterol or familial hyper cholesterolmia generally speaking input

is sought from a specialist in lipidology. Um and then they would advise on their individual case but yes there are other things that need to be done as well as genetic screen testing as well as family screening. So it is slightly different in that way. — Can someone have too low cholesterol? Um, I would say um I would say it's very unlikely that any medical therapy that we give would cause a problem where someone has too low cholesterol. Um, without meaning to give a flat answer of no, I would say it'd be very unlikely that anything we do would lower cholesterol so low that they would have any problem with making uh cell membranes or making hormones. I think that's I've certainly not seen that occur and I don't know anyone who has. Um, I'm always flat cautious about saying no. No, but I suspect not. — Okay. Uh, a food question now, Dell. What's the best swap for natural yogurt, especially accounting for the good bacteria that are in yogurt or plant-based yogurts? Okay. — Yeah. Well, I would say there isn't a good swap for natural yogurt. Natural yogurt pretty much does the job that you want it to do. Um, which is it's not fortified with um sugar. But you know, if you're using natural yogurt, it doesn't have any added sugars. Um, and you can it's your choice whether you want to decide to have lowfat or fat-free natural yogurt or full fat natural yogurt. Again, you know, we we're talking about there being no silver bullet with these things. If you're having a diet that's pretty healthy and um you're reducing your saturated fat intake in in other ways, then having full fat natural yogurt is absolutely fine. You think full fat milk is is four normally between three and four percent fat. So it's not particularly high in fat, but we do tend to eat quite a lot of dairy foods in the UK. So saturated uh fat from full fat dairy foods does contribute a bit saturated fat, but you if you choose to, you can choose the lower fat varieties. They still can say contain the same amount of protein and they still calcium. Um, I know that there are dairyfree um, milks and dairyfree yogurts available, but they tend to be highly processed. Um, and whilst they're absolutely fine if they've been fortified with calcium and they do contain some protein, um, ideally you'd want them to contain some added iodine as well if it was milk because we get most of our iodine from um, milk in this country. So, you know, fine to use plant alternatives to yogurts, but also fine to use dairy yogurts, especially if it's natural um and you're adding some nice blueberries to it, which are full of the flavvenols, the polyphenols that help um protect your arteries and help your arteries to expand and contract with the flavor flavonols in them. So, you know, it's absolutely fine to have dairy foods. full fat dairy foods, but if you're watching your weight and if you know that your saturated fat intake is a bit on the high side, I'd go for um lower fat dairy foods because you get less calories and less total fat, but you still get the same amount of calcium and protein. — Okay. Yeah. Thank you. A couple of research questions now, Chris, but uh focused on you. How do you hope your research will actually change things for patients in the future? So um thank you. I love talking about the fence. No, this is absolutely the area of my research that I'm uh really trying to drive forward is trying to accelerate the way that drugs are discovered in the field of atherosclerosis. So um so it's a really difficult field to do drug discovery in because um actually it's a really chronic disease that takes decades and decades. Events are really acute, very hard to predict. um no matter what risk stratification tool you use, it's really very hard to tell even if an individual plaque is going to cause a problem, even if it looks very nasty, it can it still may not cause a problem. And um and this is a nightmare from a drug discovery point of view because um actually you have to do really quite large studies um with thousands of patients over many years before you have any idea if your drug works. And this makes it really difficult to do adventurous drug discovery where you try and target other mechanisms outside of cholesterol. And um it also makes them really expensive and really uh really complex. Um and uh the surrogate outcomes are looking for early outcomes for drug success is uh is really tricky because calcification is a bit of a so artery calcification is not a fantastic marker for a few reasons. There aren't fantastic blood tests to see if your drugs are working. um cholesterol is quite a straightforward one to measure, but if you're trying to look at things outside of cholesterol, then there aren't great tests to do. So, um really

the body of my research is about trying to develop an imaging test which can tell you if your drug is working. And um I'm actually the study that I um supervised or uh was um looking at this um over a period of quite short period of only 90 days testing people with drugs that we know work to see if this imaging test can spot which ones which people are on the drugs that work and which people aren't. Um and then if that if this imaging test works then we can use it in a drug discovery setting to try and find new drugs that work. — Okay. I find one for you Chris uh from another questioner. What motivates you to keep going when research is slow or things don't work first time which the nature of research I suppose — yeah I don't know I suppose uh the graph I showed earlier uh when you see well actually there's been a reduction in cardiovascular mortality in the course of a single person's lifespan right this is 1950s to now and we're seeing a 75% reduction in cardiovascular mortality this is enormous the same treatments that I learned that I that were available in medical school are not the same treatments that are available now and clear didn't exist PCSK9 inhibitors were just coming about when I was born we weren't doing primary perccutaneous coronary interventions the actually things change really quickly and tav has also changed tons of stuff in cardiovascular medicine has changed really quickly and um and it's very likely that at the end of my career we'll be doing totally different things the start of my career and I want to be part of that change I also want to be giving it to patients, but I find it really exciting. It is I don't find a slow research process. Um, yeah, it's there's a lot of work that needs to be done, but it's doing something that really needs to be done. — Okay, Christopher Wall, thank you very much. Dale Stanford, thank you very much, too. Uh, that's all we have time for today. If we haven't managed to answer your question, then we encourage you to call our heart helpline and uh, speak directly to one of our cardiac nurses. Heart Matters Live is a free quarterly Q& A series and we strive to produce the best live events possible. Your feedback and comments are crucial to help plan and develop future events. So, we ask if you can please complete the survey that you'll receive in an email in the coming days. All of our incredible research is funded 100% by you, the public. If you took something away from this session or were inspired by what you heard, then all donations to support our life-saving work are very much welcomed and appreciated. There's a link to donate in the chat box should you wish to do so. This edition of Heart Manage Live was recorded and will be available on our YouTube channel from next week. Our next event will be focused on artificial intelligence, AI, and whether it can help prevent heart disease. That'll be on Tuesday the 4th of August at the same time of 1 to 2 pm. Don't miss out. Register now using the link in the chat box. Thanks again for joining us and goodbye. Thank you.