- NICE for updated guidelines.
Cholesterol & lipids
'Lipid' is the medical word for 'fat in the blood'. Too much fat in the blood is harmful. With or without diabetes, high fat levels will make many diseases more likely, such as age related macular degeneration and heart disease. But in addition, in diabetes, high blood fat levels increase complications greatly.
Generally we do need a little fat in our diet. Lipids make up the outer membranes of cells in the body, so it is essential we have do have some healthy fats in our diet.
There are two main types of fat in the blood, triglycerides and cholesterol. There are two types of cholesterol, high density lipoprotein (HDL), and low density (LDL). Triglycerides and LDL cholesterol are harmful. Many laboratories measure the 'total' cholesterol, and generally this is equivalent to the LDL level, and the lower the better.
- combination of LDL + HDL types
- ideal level <2.5, good level<3.5, target level <4.0.
- blood test can be carried out not fasting
- HDL cholesterol were thought to be protective, but new evidence suggest they make little difference.
- LDL cholesterol is definitely harmful
- a low cholesterol causes less heart disease (HPS)
- statins best for all adult diabetics, if well tolerated
- blood test ideal fasting
- very harmful if high
- treatment with fibrates first choice especially if triglyceride >4.5mmol/l (NICE)
- Low lower trigyclerides and reduce retinopathy progression by 30-40%: FIELD study recommends Fibrates to lower levels
Low cholesterol and triglyceride levels reduce diabetic complications. Average levels in the UK are 5.2 mmol/l, and these are too high. Most authorities would like lower levels...the lower the better as long as you feel well. A healthy level is <3.5mmol/l. NICE target <4.0 mmol/l. see HPS
A high cholesterol may be caused by such problems as
- genetic..you may inherit high levels
- diet.......half of cholesterol rises are due to an unhealthy western diet
- other disease, such as thyroid disease, which is common in diabetics
- diabetes causes high cholesterol and triglycerides
- being overweight.
This is most important, summarised here, in detail here.
- have a diet with very little saturated fat and transfats (these are in butter, some margarines, cakes and pastry, and often start as 'hard' fats.) Some margarines are more helpful that others..Flora is helpful. Flora pro-active and Benecol lower cholesterol. Many other margarines or butter substitutes are harmful. Some oils, such as sunflower and olive oil, are ideal in moderate amounts..latest reports indicate olive oil reduces breast cancer. Some fats such as these oils in your diet is essential. Live oil is the preferred oil when cold, sunflower or rapeseed when used for cooking. (Olive oil 'saturates' when cooked.)
- fish twice a week, especially oily fish such as sardines salmon, mackerel, tuna, will be helpful (similar DC 90)
- Salt will be harmful, including sea salt.
- Energy should come from carbohydrate such as rice, potatoes, pasta, bread
- 9 (men) 7 (women) 5 (children) portions of vegetables & fruit a day. If cooked, steaming is preferable as it preserves more vitamins. A portion is 100gm, the size of a small apple. Brightly coloured vegetables will have more vitamins, such as red cabbage, lettuce, green beans, carrots.
- Pulses, such as lentils, can provide protein, replacing some red meat. Red meat should be lean and in small amounts. Chicken and turkey are acceptable in small amounts ( the same size of a piece of weetabix).
- Meals should be balanced..some carbohydrate (rice, potato etc), vegetables, and protein such as fish or lentils (which may be made into a dahl or stew), many herbs and spices, and fruit. The amount you eat depends on your energy requirements...if you are a builder you will need to eat a lot more than someone with a desk job.
- If you are disabled you need specialist advice...indeed professional advice is important for all people with diabetes.
- See NHS
- don't smoke and have 60 minutes exercise a day..exercise is critically important
- there are diets that lower cholesterol that should be tried, eg more soya. see evidence
The benefit from statin treatment protecting the heart. Retinopathy patients will probably benefit in a similar way... progression will be halved enlarge
The main drugs to lower cholesterol are statins. Statins work on the liver so it makes less cholesterol. The target total cholesterol is <4.0 mmol/l. NICE recommend statins where tolerated for all patients >40y, and at risk patients at a younger age. Statins reduce total morbidity and mortality.
The most common side effects of the statins are abdominal pain, flatulence, diarrhoea, nausea, vomiting, headache, myalgias, rash, angioedema (allergic swelling of parts of the body). Some give insomnia, pins and needles, numbness of the fingers and toes, and other problems.
- atorvastatin Lipitor start 20mg/day 80mg common dose
- simvastatin Zocor First choice NICE. Zocor 40mg common dose increasing to 80mg if not reaching target.
- rosuvastatin Crestor for a greater drop in cholesterol start 10mg/day 5mg Asian patients
Side effects mean than about one person in 5 has to stop (my estimate). 1.5% of patients treated with statins are found to have elevated liver enzymes (chemicals), with more problems occasionally. Liver enzyme levels may rise (and the rare case of hepatitis) but get better after the statin is stopped. Liver function blood tests should be tested before starting treatment and repeated now and again. Sometimes other medications may lead to liver and muscle problems if given together with a statin.
Statins are now recommended for most adults with diabetes, and should be used if there are no side effects. If one statin causes side effects, that drug should be stopped. Generally one of the others should be tried, and often the alternative will have no side effects. If all of the statins cause side effects, naturally none can be used. Some people have a specific genetic pattern that makes them susceptible to muscle problems. Statin myopathy (BMJ 2008).
- Simvastatin...you MUST avoid grapefruit juice see
- Simvastatin...avoid certain anti-fungal/HIV treatment.
- Any person using a statin should report muscle pain, weakness, or cramps. Muscle enzymes will need to be tested with a blood test and you may need to stop treatment if they are above a certain level.
- Avoid excess alcohol
- rosuvastatin (Crestor) 5-10mg/day... must be started at this dose, no higher
- if myalgia develops, see BMJ 2012
Patients who are taking statins should avoid or minimise alcohol, and should not use a statin if the liver is very abnormal.
Anyone using statins who thinks they have side effects from then should ask their doctor or nurse. Concerning milder side effects, one option is to stop the statin and see if you feel better after 1-2 weeks. Then restart them and see if you feel bad again. This helps to confirm the statin is causing the side effect. You should discuss the situation with your doctor if you get side effects.
Many people using statins notice dry sore eyes. This may be a coincidence, and is not harmful. If your eyes are dry, ask for lubricants.
Rosuvastatin (Crestor) is is more powerful than others. It must be started at the lowest 5mg dose in certain patients (Asians, reduced kidney function, thyroids problems, muscle disorders..personal/in family, alcohol abuse, >70y, fibrate use). When used at this dose it occasionally causes problems, more often that the manufacturer states. However, if used with care local opinion advises it is safe to be prescribed in general practice....it is useful when the cholesterol drop with the other drugs (at their lower dose) is insufficient, and you need the cholesterol lower still.
It causes similar problems to the other statins as described on this page. At higher dose it is more likely to cause rhabdomyolysis (a serious muscle problem which can begin quickly). Myopathy BMJ
- add to the effect of a statin
- can reduce the dose of statin for the same cholesterol lowering effect
- controversial...some publications indicate little advantage
Ezetrol together with a statin lowers the cholesterol further. There are normally no side effects. Adding to a statin lowers the cholesterol 25% extra. Ezetrol works by reducing cholesterol absorption from the gut, whereas statins reduce the production of cholesterol by the liver. Details here at netdoctor .
Triglycerides levels drop if you
- lose weight (if overweight)
- exercise more
- avoid too much alcohol.
But fibrates lower triglycerides
- lower triglyceride, and is more effective than a statin for this
- consider for all exudative retinopathy
Fibrates are recommeded for nearly everyone with retinopathy, with benefit shown in the FIELD study. (If GFR >15 & no pancreatititis.) See Eye 2011 and the FIELD study. But such studies suggest they will be just as useful for patients with a normal triglyeride, and should probably be used in most patients (except younger patients): fenofibrate 200 mg/day. Nice recommend fibrates if triglyceride >4.5mmol/l, but we believe thisis outdated advice...they benefit nealy everyone with retinopathy. The FIELD study identifies a 30%-40% reduction in retinopathy development when given early before complications. This is a very important study, and clearly many patients with highish triglycerides should be prescribed a fibrate such as Supralip. It may be that fenofibrate should be used in every person with exudative maculopathy. Some local experts suggest that fenofibrate 200 mg/day should be recommended to all adult patients unless there are contra-indications:
- either alone or in addition to a statin
- side effects are not common; serious side effects are very unusual
- for all adult patients even those without retinopathy.
- fenofibrate..lower dose if renal function reduced, BNF 2012
- eGFR > 60...200mg
- 60 > eGFR > 20..134mg
- 20 > eGFR > 15..67mg
- none if GFR <15
- fibrates etc £72/year.