High cholesterol is a silent killer that affects 39% of Singaporeans aged 18-74. Unlike high blood pressure and blood sugar that can be monitored at home using simple devices, high cholesterol can only be measured with the help of a doctor. Regular monitoring of our cholesterol levels will help us assess and manage the risk of heart disease or stroke.
While medications can effectively help manage high cholesterol, it is important to make lifestyle changes as well to mitigate rising cholesterol levels. Making smart changes in our diet and incorporating more physical activity in our daily life can go a long way in safeguarding our health.
With National Heart Week and World Heart Day falling on 29 September, the Singapore Heart Foundation (SHF) is highlighting cholesterol this year as a risk factor. We spoke to Ms Natalie Yeo, Dietitian at SHF to share more about how to monitor our cholesterol levels and some lifestyle changes to improve cholesterol levels.
Q: How important is it to monitor our cholesterol levels and how often should we do so?
Lowering cholesterol levels prevents disease in normal people without any established cardiovascular disease (primary prevention) and in high-risk patients who have previous heart attacks, strokes or have undergone coronary stenting or coronary artery bypass operations (secondary prevention).
Similar to high blood pressure, high blood cholesterol is a silent killer that does not present any symptoms. It can only be detected through a cholesterol test. It is important to monitor our blood cholesterol levels as having high blood cholesterol affects heart health, and knowing our condition helps with disease prevention.
According to the Ministry of Health, adults should get their cholesterol checked once every three years¹. Individuals with a higher risk of high blood cholesterol, such as strong family history, smoking history, obesity, diabetes mellitus or hypertension, may require closer monitoring of cholesterol levels at the direction of their doctors.
It is recommended for men and women aged 40 years and older to screen for lipid disorders routinely². This should be carried out even as young as 18 years of age if a person has other risk factors such as a family history of premature coronary death, smoking, obesity, diabetes mellitus etc.
Q: How will lifestyle and diet changes make a difference in our body’s cholesterol level?
80% of the cholesterol in our body is produced by the liver, and the rest comes from the food we eat. Hence, it is essential to be mindful of the foods we eat as they could tip cholesterol levels without our knowledge.
For most healthy individuals, dietary cholesterol has a modest effect on blood cholesterol levels, but limiting the amount of cholesterol you consume remains important, as foods that are rich in cholesterol generally tend to be rich in saturated fat (bad fat). Individuals with diabetes, high blood cholesterol and heart disease risk should practice caution as they are more sensitive to changes in blood cholesterol. Do consult your doctor, who will be able to recommend your cholesterol intake based on your health condition.
Studies have shown that compared to dietary cholesterol, the fats in our diet have more impact on blood cholesterol levels. A diet rich in bad fats (i.e., saturated fat and trans fat) can raise our LDL (‘bad’) cholesterol levels, increasing our risk for heart disease and stroke. On the other hand, a diet rich in good fats (i.e., monounsaturated fat and polyunsaturated fat) supports the lowering of LDL (‘bad’) cholesterol and increases HDL (‘good’) cholesterol, thus lowering our cardiovascular disease risk.
It is encouraged to limit total fat intake and replace bad fats with good fats in moderation. Increasing our fibre intake, specifically soluble fibre, helps slow down and bind cholesterol in the intestine and transport them out of our bodies. This, in turn, helps lower LDL (‘bad’) cholesterol.
In general, a balanced diet, incorporating an active lifestyle, maintaining a healthy BMI (18.5-22.9kg/m2), quitting smoking and drinking alcohol in moderation helps manage our cholesterol levels.
Those diagnosed with high blood cholesterol will have to rely on a combination of lifestyle changes and medications. Lifestyle changes should not be viewed as an alternative therapy to medicines, and likewise, we cannot rely on medications alone to manage high cholesterol effectively without making lifestyle changes.
Q: What types of cholesterol-friendly foods can we add to our diet that can be easily accessed at supermarkets?
1. Lean Protein
- Fresh lean meat, skinless poultry (lean chicken breast etc.), fish (white-fleshed etc.)
- Eggs, dairy such as low-fat milk, yoghurt, reduced sugar/unsweetened soymilk
- Plant-based proteins such as tofu, tempeh, beans, peas, lentils, legumes (e.g. green beans, red beans, kidney beans, chickpeas [garbanzo beans], black beans, pinto beans)
2. Good fats in moderation
- Sources of monounsaturated fat include unsalted baked nuts (e.g. almonds, hazelnuts, pistachio kernels, cashew nuts, macadamias, pecans, pine nuts) and heart-healthier oils (i.e., canola oil, olive oil, sesame oil, avocado oil, flaxseed oil, sunflower oil, corn oil)
- Sources of polyunsaturated fats include fatty fishes rich in omega-3 (e.g. salmon, mackerel, sardines, herrings); products enriched or fortified with omega-3; and foods rich in omega-6 (e.g. corn oil, sunflower oil, seeds such as sunflower seeds, sesame seeds)
3. Foods rich in fibre
- Whole-grains (e.g. oats, brown rice, millet, quinoa, buckwheat soba, wholewheat pasta, wholemeal bread, quinoa, barley, corn,
brown rice vermicelli)
- Fruit and vegetables
- Legumes (e.g. beans, peas, lentils, soybeans)
- Nuts and seeds (unsalted, baked)
SHF has worked with the Shopee Supermarket team to analyse, filter and categorise cholesterol-friendly foods available on the Shopee Supermarket. The categories include beverages, food staples, breakfast essentials and snacks will be made available from 17 Sep to 12 Oct 2022 on shopee.sg/supermarket, which will ease the shopping experience for consumers looking to make heart healthier food choices.
Q:What are some cholesterol-friendly replacements we can make when enjoying our favourite local dishes?
Limit intake of saturated fat by:
- Asking for less oil and/or gravy
- Go for plain rice over flavoured/fried rice
- Opt for clear-based soup instead of creamy/coconut-based gravies, but limit the intake of soup as they can be high in sodium
- Remove visible fats or skin, limit organ meats and shellfish and opt for lean protein (i.e sliced fish, lean cuts of chicken/meat, tofu, beans)
- Go for boiled, baked, grilled dishes instead of deep-fried foods
- Limit processed meats and opt for fresh ingredients
- Asking for more vegetables, incorporate lean protein options and aim for a heart-smart eating plate concept (¼ plate of carbohydrates (preferably wholegrains), ¼ plate lean protein and ½ plate fruit and vegetables) when possible
Q: What lifestyle changes can we make to raise HDL cholesterol?
- Focus on a heart-healthy balanced diet. Opt for a diet rich in fibre, with a variety of lean protein, and minimise intake of bad fats (saturated fat and trans fat), replacing them with good fats (monounsaturated and polyunsaturated fat) in moderation.
- Be mindful of refined carbohydrates (processed grains, sugars), sweetened beverages.
- Follow the Singapore Heart Foundation’s ‘Heart Smart Eating Plate’ concept to maximise nutrient intake and practice portion control to prevent weight gain and reap benefits for your heart.
- Limit alcohol consumption. Alcohol is high in calories and sugar and has a potent effect on triglycerides, a type of fat that is found in our blood. Our bodies convert excess calories that we do not require into triglycerides to be stored in our fat cells. When triglyceride levels are high, it can build up and increase your risk of cardiovascular disease. Hence if you drink, do so in moderation. Have no more than one standard drink a day for women and two drinks a day for men. A standard drink refers to:
- ²⁄3 can (220ml) regular beer, or
- ½ glass (100ml) of wine, or
- 1 nip (30ml) of spirit
Though the impact of regular physical exercise on LDL-cholesterol levels is very limited, it may however increase HDL cholesterol modestly. An increase of HDL levels by 6 mg/dL (0.15 mmol/L) may be achieved with 25 to 30 km of brisk walking per week.
Exercise can also improve the lipid profile (reduce triglycerides, increase HDL-C) of an individual by causing weight loss. This may be especially useful for obese persons as a decrease in LDL concentration of 8mg/dL (0.2 mmol/L) can be observed for every 10kg of weight loss.
The general population are encouraged to exercise at moderate intensity for 150 to 300 minutes per week. Individuals with abnormally high cholesterol levels are advised to consult their doctor or physiotherapist for a guide on intensity and duration of exercise.
Smoking decreases HDL and damages the walls of the artery, causing LDL build-up.
Q: What should we avoid or limit to manage our cholesterol levels?
Aside from the lifestyle changes mentioned above, we recommend the following ways to manage cholesterol levels:
- Reduce consumption of bad fats (saturated fat and trans fat) and consumption of baked products such as cakes, cookies, pastries and commercially deep-fried foods
- To be safe, limit cholesterol intake to less than 300mg per day. Avoid consuming organ meat and shellfish more than twice a week
- Reduce intake of refined carbohydrates (such as processed grains, sugar)
- Limit deep-fried foods to no more than twice a week. Choose healthier cooking methods like grilling, steaming and pan-frying instead of deep- frying
¹and ² https://www.moh.gov.sg/docs/librariesprovider4/guidelines/moh-lipids-cpg—booklet.pdf
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