Singaporeans are living better lives than ever, with greater dining choices and higher incomes that allow us to indulge in one of our favourite national past-times: eating. But are our hearts paying the price?
In 2018, ischaemic and other heart diseases accounted for a combined 5.6% of all hospital admissions1. And judging from our love for red meat, shellfish, fried food, desserts and alcohol, high cholesterol might have something to do with it.
High cholesterol, where there are above-normal levels of waxy, fat-like substance (cholesterol) in the blood, is a growing problem here. The number of 18- to 69-year-olds diagnosed with hyperlipidaemia (high cholesterol) rose from 25.2% in 2010 to 33.6% in 20172.
High blood cholesterol is one of the common risk factors of cardiovascular disease. In 2019, ischaemic and other heart diseases and cerebrovascular heart disease (including stroke) accounted for 26.6% or about one in four of all deaths in Singapore3.
Generally, the recommended age to start having regular cholesterol level checks is 40. So if you’re a thin 28-year-old, you’re “safe”, right? Maybe not. We ask Dr Tan Svenszeat, a cardiologist at Orchard Heart Specialist Clinic, about Singapore’s cholesterol problem and when exactly you should see a heart specialist.
What’s to blame for the rising number of high cholesterol cases in Singapore?
One reason is our ageing population, as the effects of bad cholesterol tend to build up over time. Another reason is the growing population of overweight (including obese) individuals in Singapore.
Being overweight itself is correlated to the development of hypertension (high blood pressure), high cholesterol and pre-diabetes. This entity in medical terms is called metabolic syndrome, where the cluster of conditions or risk factors tends to occur together. When an individual has metabolic syndrome, they have a higher risk of heart disease, stroke and Type 2 diabetes.
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Why is this a cause for alarm?
The degree of elevated cholesterol is directly related to the increased risk of a cardiovascular event like a heart attack or stroke. High cholesterol that is uncontrolled for a long period may lead to accumulation of cholesterol and hardening of the arteries, also known as atherosclerosis. Over time, this build-up will cause progressive narrowing of the arteries, and inevitably lead to a stroke or heart attack.
Why is high cholesterol, even in your 30s and 40s, worrying?
Elevated cholesterol levels may cause permanent cholesterol build-up in the arteries. This process may start as early as 40 years old, or younger. The degree of cholesterol built up in the arteries is proportionally related to the duration of high cholesterol in the body. This means that the longer one’s cholesterol level is poorly managed, the more severe the cholesterol build-up would be. This in turn may lead to early heart attack or stroke.
Is it only obese, inactive people in their 20s and 30s who need to watch their cholesterol, or do thin people in this age group also have reason to worry about high cholesterol?
Thin people, although their risk for heart disease is low, should still be vigilant if they have a strong family history of heart disease and high cholesterol. These individuals may have inherent issue with high cholesterol which may go undetected for years if not screened.
Will getting regular cholesterol level checks before age 40 help?
The recommended age for cholesterol level checks is 40 years old based on the European, American and Singapore guidelines. However, there are certain groups of individuals under 40 years old who would need cholesterol level checks as they have high risk factors for artery disease. The first group is those with diabetes mellitus, hypertension or pre-diabetes, and smokers. People with a strong family history of cardiovascular disease before the age of 50 years in male relatives or before age 60 years in female relatives and a family history of extremely high cholesterol would also be advised to start screening at an earlier age.
For these groups, getting screened at a younger age will allow your doctor to identify abnormalities early or recommend more frequent cholesterol level screenings for closer monitoring. They may also advise regular cardiovascular screenings, further evaluations for heart disease as well as devise a plan to achieve a healthy cholesterol target that cuts your risk of a heart attack or stroke.
These groups with inherited high cholesterol will usually have very high cholesterol levels. It is usually at a level that needs initiation of cholesterol medication even at the age of 20 years old.
So, what’s the best age to start getting screened?
Based on the guideline recommendations, without any cardiovascular risk factors, the best age to start cholesterol screening is at the age of 40 years old for the general population. Those who have risk factors, especially those with a strong family history of high cholesterol, can have screening done even as early as two years old. Doing so at an early age allows for opportunities to teach individuals to be more aware of their cholesterol levels and adopt healthy lifestyle habits such as good eating practices and incorporating regular physical activity to their daily lives.
What are some ways to keep cholesterol levels within the healthy range and reduce the risk for stroke?
The degree of benefit one can get from lowering their cholesterol depends on their overall risk. A person with established artery blockage may have a different treatment strategy compared to a person who is completely disease-free aside from having high cholesterol levels. In both scenarios, lifestyle modification is needed. The two elements that can effect a healthy change are diet and exercise.
Diet: I usually recommend the Mediterranean diet, which is rich in vegetables, fruits and fish. Reduce intake of red meat and processed meat, and swap them for chicken, without the skin.
Exercise: Exercise regularly for at least 150 minutes a week. This translates to at least 30 minutes a day, five times a week. Even brisk walking counts.
If one has concomitant cholesterol build-up in the arteries, we’d recommend medications together with lifestyle changes.
When should one see a heart specialist and what can be done to help high cholesterol patients?
In most cases, high cholesterol is usually managed by a general practitioner. One should start seeing a heart specialist when they experience chest pain and shortness of breath during exercise or when a screening test suggests heart artery disease. We can then perform some tests to the heart, to make a diagnosis of the heart artery narrowing. We can also assess whether this narrowing increases the individual’s risk of a future heart attack. If the arterial narrowing is severe, we can unblock the arteries through a procedure called angioplasty which involves ballooning and stenting.
A heart specialist can also help patients whose cholesterol levels are particularly difficult to control. This usually occurs among people with a strong family history of high cholesterol. We can then initiate specialised treatment to lower the cholesterol level.
What can be expected during a consultation with a heart specialist?
Patients may be advised to do some tests to ascertain whether they have heart artery blockage and an assessment of severity of the blockage. The two most common tests to detect this are the stress test or a CT scan of the heart artery. In cases where there is heart artery blockage, you and your cardiologist can discuss possible treatment options as well as how aggressively to treat the high cholesterol.
1 Ministry of Health, Top 10 Conditions of Hospitalisation, retrieved on 30 September 2020 from https://www.moh.gov.sg/resources-statistics/singapore-health-facts/top-10-conditions-of-hospitalisation
2 Ministry of Health, Disease Burden, retrieved on 30 September 2020 from https://www.moh.gov.sg/resources-statistics/singapore-health-facts/disease-burden
3 Ministry of Health, Principal Causes of Death, retrieved on 30 September 2020 from https://www.moh.gov.sg/resources-statistics/singapore-health-facts/principal-causes-of-death