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A CROSS SECTIONAL STUDY ON THE PREVALENCE, KNOWLEDGE, ATTITUDE AND PRACTICE OF

HYPERCHOLESTEROLAEMIA AMONG THE SAMPLED POPULATION OF AGE 35 YEARS AND ABOVE IN KAMPUNG

SADONG JAYA FROM 14th JUNE TO 20th AUGUST 2004

Report by YEAR 4 MEDICAL STUDENTS

GROUP 1 COMMUNITY MEDICINE AND PUBLIC HEALTH POSTING:

Yang Boon Yon Zuffazarina binti Zulkapli

Thanuja a/p Mahaletchumy Shazni Izana binti Shahruddin

Peter ak Jerampang Koe Hooi Ming

Daphne Dewi ak Stephen Kalong

Alex Lee Fook Seng Aisah Munirah binti Wahi Norizan binti R. osli Noor Suhaila binti Abu Bakar Mursyida binti Md Nujid Mariza binti Md Rasip Adeline Kueh Mei Ling

Pusat lCluacnai lvtui: lur[taº Aic. ̂. cicmik UNIVERSI'll MALAYSIA SARAWAK

FACULTY OF MEDICINE AND HEALTH SCIENCES,

UNIVERSITY OF MALAYSIA SARAWAK

,0

ý; ý R`ý

A CROSS SECTIONAL STUDY ON THE PREVALENCE, KNOWLEDGE, ATTITUDE AND PRACTICE OF

HYPERCHOLESTEROLAEMIA AMONG THE SAMPLED POPULATION OF AGE 35 YEARS AND ABOVE IN

KAMPUNG SADONG JAYA FROM 14TH JUNE TO 20TH AUGUST 2004

Report by YEAR 4 MEDICAL STUDENTS

GROUP 1 COMMUNITY MEDICINE AND PUBLIC HEALTH POSTING:

Yang Boon Yon 7642 Zuffazarina binti Zulkapli 7305 Thanuja a/p Mahaletchumy 7219 Shazni Izana binti Shahruddin 7133 Peter ak Jerampang 7026 Koe Hooi Ming 6676 Daphne Dewi ak Stephen Kalong 6432 Alex Lee Fook Seng 6263 Aisah Munirah binti Wahi 6259 Norman binti Rosli 6084 Noor Suhaila binti Abu Bakar 6051 Mursyida binti Md Nujid 6029 Mariza binti Md Rasip 3258 Adeline Kueh Mei Ling 6226

DECLARATION

We, the research team members whose names appears herein below hereby declare that this

research is our own original work with the exception of quotations of the works in which we

had stated their sources.

Yang Boon Yon 7642

Zuffazarina binti Zulkapli 7305

Thanuja a/p Mahaletchumy 7219

Shazni Izana binti Shahruddin 7133

Peter ak Jerampang 7026

Koe Hooi Ming 6676

Daphne Dewi ak Stephen Kalong 6432

Alex Lee Fook Seng 6263

Aisah Munirah binti Wahi 6259

Norizan binti Rosli 6084

Noor Suhaila binti Abu Bakar 6051

Mursyida binti Md Nujid 6029

Mariza binti Md Rasip 3258

Adeline Kueh Mei Ling 6226

i

ACKNOWLEDGEMENT

Embarking upon the journey in completing this daunting task, no words could

compensate the gratitude we fell towards those that have been a big help in completing our

report. Thus, we would like to extend our most sincere thank you to those who were

involved directly or indirectly in making this research a success. First and foremost, we

would like to convey our deepest appreciation to Penghulu Tuan Haji Yaakob Matsir,

members of Jawatankuasa Kemajuan dan Keselamatan Kampung (Village Committee) and

all the residents of Kampung Sadong Jaya.

We would like to express our heartfelt appreciation to University Malaysia Sarawak

(UNIMAS) for extending her full cooperation towards the success of this project. We would

like to express our sincere gratitude to Mr Cliffton Akoi anak Pangarah, and Dr Kamaluddin

Bakar, coordinators of Community Medicine and Public Health Posting, who contributed

tremendously through time, advice and guidance towards the success of our research.

We further extend our sincere gratitude to Professor Dr. Hashami Bohari, Deputy

Dean of Medicine and Health Science Faculty; Associate Professor Dr. Mariah Ahmad,

Associate Professor Dr. Win Kyi and Puan Rasidah Abd. Wahab for their support, guidance

and encouragement.

We would also like to acknowledge Professor Dr Syed Hassan Ahmad Al-Mashoor,

Dean of Faculty of Medicine and Health Sciences UNIMAS, all lecturers and other staff

members of the faculty for their help and support in any forms, towards a success in our

research and intervention programme

11

We would like to further express our heartfelt gratitude to the Divisional Health

Office of Kota Samarahan and all the staff members of Klinik Kesihatan Sadong Jaya for

their support and cooperation during our posting in Sadong Jaya.

Our appreciation is also extended to those who were directly or indirectly involved in

our community program and all the individuals as well as companies who had given their

fullest support in the forms of finance and materials.

Last but not least, our deepest gratitude is extended to all the 14 members of the group

for their commitment and contribution of productive ideas for the successful completion of

this research.

ül

ABSTRAK

Hiperkolesterolemia ialah suatu keadaan penyakit yang semakin meningkat di seluruh dunia, terutamanya kerana perubahan pada gaya hidup dan juga amalan pemakanan. Keadaan ini adalah disebabkan oleh kandungan kolesterol yang tinggi dalam darah. Hiperkolesterolemia

merupakan salah satu risiko utama berlakunya penyakit jantung. Walaupun hiperkolesterolemia selalunya dianggap sebagai ̀penyakit penduduk bandar', tetapi disebabkan Malaysia sedang berkembang pesat sebagai sebuah negara moden pesat, kesan-kesan

urbanisasi, terutamanya dari sudut kesihatan, kawasan luar banda juga akan turut mengalami tempiasnya.

Satu kajian rentas ke atas prevalens, pengetahuan, amalan dan perlakuan terhadap hiperkolesterolemia di kalangan sample populasi yang berumur 35 tahun dan ke atas telah dijalankan di Kampung Sadong Jaya.

Melalui kaedah bancian dan EPI Info 6.04, seramai 150 responden telah dipilih secara rawak. Temuramah dan pengukuran tahap kolesterol dalam darah telah dilakukan ke atas setiap responden. Antara kriteria pengecualian yand telah diambil kira dlah mereka yang terlampau sakit dan telah menolak dari menurut serta melakukan kaji selidik selepas tiga kali

percubaan.

Melalui kajian yang dilaksanakan, hanya separuh daripada responden, iaitu sebanyak 55.0% mempunyai pengetahuan yang baik tentang hiperkolesterolemia, manakala sebanayk 45.0% lagi tidak. Tambahan lagi, terdapat 60.0% responden yang mempunyai sikap yang betul dan sebanyak 40.0% mempunyai sikap yang salah terhadap hiperolesterolemia. Sebanyak 54.0% responden mempunyai amalan yang baik terhadap hiperkolesterolemia, dan selebihnya sebanayk 46.0% tidak. Daripada kajian yang telah dilakukan juga, privalens mereka yang mempunyai tahap kolesterol keseluruhan yang optimum (kurang dari 5.20 mmol/1) adalah sebanyak 69.0%. Bagi mereka yang mempunyai tahap kolesterol keseluruhan yang atas garis garis sempadan (dari 5.21 mmol/l ke 6.20 mmol/l) pula adalah sebanyak 25.0%. Didapati,

sebanayk 6.0% responden mempunyai risiko yang tinggi terhadap hiperkolesterolemia (lebih dari 6.20 mmoVl)

ABSTRACT

Hypercholesterolaemia is a disease condition, which is on the rise worldwide, owing mainly due to the changes in lifestyle and dietary habits. It is a condition where there is excess cholesterol in the blood. It is one of the major risk factors for cardiovascular mortality. Although hypercholesterolaemia is normally thought as a `disease among the urban', but since Malaysia is progressively encroaching modernization, the effect of urbanization, especially regarding health, will leak towards it's surrounding area, including the rural parts.

A cross-sectional study on the prevalence, knowledge, attitude and practice of hypercholesterolaemia among the sampled population aged 35 years old and above was carried out in Kampung Sadong Jaya.

Through census and EPI info 6.04 a total of 150 respondents were randomly selected for questionnaire interviews, measurements of total cholesterol level and body mass index. The exclusion criteria include those who are severely ill, and those that refuses even after 3 attempts of approaching the respondent fails.

From the research that has been conducted, only about half of the respondents, which accounts towards 55.0%, had good knowledge regarding Hypercholesterolaemia while another 45.0% did not. Furthermore, there were 60.0% of respondents having good attitude and another 40.0% have unhealthy attitude regarding Hypercholesterolaemia. A percentage of 54.0% respondents have good practice while another 46.0% did not. As for the prevalence of hypercholesterolaemia among the respondents, 69.0% of the respondents had desirable total cholesterol (less than 5.20 mmol/1), 25.0% had borderline hypercholesterolaemia (from 5.21 mmol/l to 6.20 mmol/1) while 6.0 % had high risk of hypercholesterolaemia (more than 6.20 mmol/1).

V

UIVIVERSTI] MALAYSIA SARgwAK

CONTENT

TABLE OF CONTENTS

DECLARATION

ACKNOWLEDGEMENT

ABSTRACT

ABSTRAK

CONTENTS

LIST OF TABLES

LIST OF FIGURES

CHAPTER I INTRODUCTION AND BACKGROUND

1.1 Introduction

1.2 Background information

CHAPTER II RESEARCH PROBLEM AND LITERATURE

REVIEW

2.1 Research Problem

2.2 Literature Review

CHAPTER III OBJECTIVES AND HYPOTHESES

3.1 General objective

3.2 Specific objectives

3.3 Research Hypotheses

CHAPTER IV RESEARCH METHODOLOGY

4.1 Research design

Page

i

I1

iv

V

V1

ix

X

1

4

7

10

18

18

19

20

vi

4.2 Research setting

4.3 Population and sampling

4.4 Study Instrument

4.5 Data collection and data analysis

4.6 Research methodology flow chart

4.7 Operational definition

CHAPTER V RESULTS

5.1 Sociodemography

5.2 Knowledge on Hypercholesterolaemia

5.3 Attitude on Hypercholesterolaemia

5.4 Practice on Hypercholesterolaemia

5.5 Prevalence of Hypercholesterolaemia

5.6 Body Mass Index

5.7 Level of knowledge with level of attitude

5.8 Level of knowledge with level of attitude

CHAPTER VI DISCUSSION

6.1 Introduction

6.2 Knowledge on Hypercholesterolaemia

6.3 Attitude on Hypercholesterolaemia

6.4 Practice of Hypercholesterolaemia

6.5 Prevalence of hypercholesterolaemia

CHAPTER VII LIMITATION, RECOMMENDATION AND CONCLUSION

20

20

21

22

23

24

29

32

45

49

58

65

66

67

69

69

71

72

72

vii

7.1 Limitation

7.2 Recommendation

7.3 Conclusion

BIBLIOGRAPHY

APPENDICES

I. Organisational Chart of the Research Team

II. Map of Kampung Sadong Jaya

III. Questionnaire

a. Englishn version

b. Malay version

c. Bahasa Melayu Sarawak version

IV. Census card

V. Group Activity Photos

76

78

78

80

84

85

86

92

99

105

106

viii

LIST OF TABLES

NO TITLE 1 Mean and standard deviation of age with gender among the

respondents

PAGE 29

2 Answers Regarding Knowledge on the meaning of cholesterol, HDL 32

and LDL

3 Knowledge on the association between diet and hypercholesterolaemia 34

4 Respondents' knowledge about methods of cooking that increase 35 cholesterol in food.

5 The respondents' knowledge on non-dietary risk factors of 37 hypercholesterolaemia.

6 The respondents' knowledge on non-dietary risk factors of 38 hypercholesterolaem. ia.

7 Level of Knowledge of Respondents according to Gender 43

8 Mean Age and Standard Deviation of Age according of 43 Respondents with for Good and Bad Knowledge

9 Mean and Standard Deviation of Income according to Knowledge 44

10 Relationship between Knowledge and Educational Level of 44 Respondents

11 Answer of Respondents Regarding Food Preparation Methods 51

12 Percentage of Respondents according to Types of Food and Units 51-52 of food intake within a week

13 Percentage of High Fiber Food Intake among the Respondents 53

14 Percentage of Respondents according to Frequency of Weight 56 Measurement

ix

LIST OF FIGURES

NO FIGURES PAGES I Percentage of The Respondents according to Educational Level 30

2 Monthly Household Income of Respondents 31

3 Answer for the Question 36

4 Percentage of Respondents With Good Knowledge on Types of 36 Food High in Cholesterol

5 Percentage of Respondents Having Good Knowledge on Methods of 38 Cooking That Could Increases Cholesterol Level

6 Percentage of Respondents Having Good Knowledge on Non- 39 Dietary Risk Factors and the Prevention of Hypercholesterolaemia

7 Knowledge of Respondents on Complications of Hypercholesterolaemia

40

8 Percentage of Respondents Having Good Knowledge on the 41 Conditions Related to Hypercholesterolaemia

9 Percentage of Respondents with Knowledge on the Availability of 41 Pharmacotheray for the Control of Hypercholesterolaemia

10 Knowledge Regarding Hypercholesterolaemia 42

11 Percentage of Answer for each Question regarding to Attitude of 45 Food Modification among the Respondents.

12 Percentage of Respondents towards the Willingness to Exercise 46 assumed to be Normal and to have Hypercholesterolaemia

13 Willingness to Stop Smoking if have Hypercholesterolaemia 47

14 Answers towards the Willingness to Seek for Treatment 48

15 Attitude of the Respondents towards Hypercholesterolaemia 49

X

16 Food Preparation Methods 50

17 Cholesterol Level in the Diet of the Respondents 52

18 Frequency of Eating Out among Respondents 54

19 Percentage of Respondents Exercise at Least 3 Times per Week 55

20 Number of Respondents Had Screened Their Cholesterol Before. 57

21 Practice to Prevent Hypercholesterolaemia 58

22 Total Cholesterol Level of Respondents 59

23 Scattergram Showing Distribution of Total Cholesterol Level 60 according to Age

24 Level of Total Cholesterol with Gender 61

25 Level of Total Cholesterol with Race 62

26 Level of Total Cholesterol with Educational Level 63

27 Total Cholesterol Level in mmol/l with Monthly Household Income 64

28 Level of Total Cholesterol with Cholesterol Level In Diet 65

29 Body Mass Index of Respondents 66

30 Scattergram Showing Distribution of Total Cholesterol Level 67 according to Body Mass Index

31 Relationship between Level of Knowledge and Level of Attitude 68 on Hypercholesterolaemia

32 Relationship between Knowledge and Practice 69

XI

CHAPTER 1

INTRODUCTION AND BACKGROUND

1.1 Introduction

Hypercholestrolaemia is a condition in which the level of cholesterol in the blood is

high. When there is too much cholesterol, deposits of fat in the blood called plaque form inside

blood vessel walls. This causes the blood vessel walls to thicken and become narrower. This

change in the blood vessels reduces blood flow through the blood vessels, increasing the risk

of coronary heart disease (Ehnholm et al, 1982).

A period of over 20 years of sustained economic growth and political stability has

made Malaysia one of the most buoyant Southeast Asian countries. Such rapid advancements

in the socio-economic situation in the countries in Asia, resulted in significant changes in the

life-styles of communities, including food habits, and food purchasing and consumption

patterns. The shift towards to the "westernized" dietary pattern has also brought about a new

nutrition scenario in our country. These has caused some segments of the communities to

suffer from the problems of hypercholestrolaemia and associated disorders in other groups.

These disorders, frequently termed the diet-related chronic non-communicable diseases include

coronary heart disease as the major one (WHO, 1996).

Serum cholesterol concentrations vary widely throughout the world. Generally,

countries associated with low serum cholesterol concentrations (eg, Japan) have lower CHD

event rates, while countries associated with very high serum cholesterol concentrations (eg,

Finland) have very high CHD event rates. However, some populations with similar total

1

cholesterol levels have very different CHD event rates, suggesting that other factors also

influence CHD risk (Brown, 1986). Therefore, it is vital to identify all the risk factors

involved in elevation of cholesterol level.

In Malaysia, rapid and marked socioeconomic advancements for the past decades have

brought about significant changes in the lifestyle of communities. These include significant

changes in the dietary patterns of Malaysian, for example the increase in consumption of fats

and oils and refined carbohydrates and a decreased intake of complex carbohydrates (Tee, Ng

& Azriman, 1999).

Several epidemiological studies which were conducted in Malaysia on risk factors of

coronary heart disease have shown that hypercholesterolemia was a problem amongst the more

affluent segments of the population whereas the rural population have lower levels of serum

cholesterol of about 3.6 mmol/L. Urban Malaysian were found to have higher serum

cholesterol level (Tee et al, 1999). Urban Malaysians were found to have the highest serum

cholesterol levels of 4.2-4.4 mmol/L. The prevalence of hypercholesterolemia amongst this

group is almost 30% (Ministry of Health, 1997).

The mean blood cholesterol level for the aborigines in west Malaysia was found to be

low at about 3.8mmol/L and none of them were hypercholesterolaemic. The average

cholesterol level among poor rural Malay men was reported to be also low, at 3.6mmol/L

(Khor et al, 1997).

Among the main ethnic groups, Indians are reported to have the highest prevalence of

hypercholesterolaemia (43.2%), as compared to 35.2% and 24.2% among the Malays and

Chinese respectively. Earlier studies did not find a significantly higher prevalence of

hypercholesterolaemia among the Indians than the Chinese and Malays. This development is

2

of significance in light of the fact that the Indians presently show the highest mortality rate for

coronary heart disease (Ministry of Health, 1997).

World wide, due to marked geographical differences in the incidence of coronary heart

disease within the countries and early study about these interpopulation differences was done

which known as The Seven Countries Study. It was found that the median cholesterol levels

which were very high are correlated with increased coronary heart mortality (Seven Countries

studies, 1980).

All the above evidence clearly shows that hypercholestrolaemia is in the rise among

almost all societies both in Malaysia as well as in the world. It is therefore a step in the right

direction to conduct a research on this aspect. By assessing the knowledge, attitude and

practice of people regarding hypercholestrolaemia, would help to identify the problem at the

grassroot level. By assessing the prevalence of hypercholestrolaemia we aim to identify the

target group so that future strategies for nutrition education can be carried out effectively.

Another importance is so that more effective dissemination of information regarding this

health topic could be done. At the same time, we can determine how best to promote healthy

eating within the present scenario of rapid urbanization, "western" dietary pattern influence, a

whole barrage of convenience and " health" foods and nutrition misinformation.

It is hoped that this research would contribute to enriching the knowledge on

hypercholestrolemia and the ways to reduce it among the rural community of Kampung

Sadong Jaya.

3

1.2 Background

Geographical location

Kampung Sadong Jaya, an area in the district of Sadong Jaya and Kota Samarahan

division is a Malay community area, which is located in close vicinity to the South China Sea.

It is situated approximately 70 km from Kuching and can be accessed either via road or river.

Population and organization

According to the statistics of year 2004, the population of Kampung Sadong Jaya

stands at 1162 which consists 9.75% of the total population of Sadong Jaya. The largest ethnic

group here is Malay (70%) followed by Bugis (12%), Jawa (13%), Chinese (4%) and others

(1%). A census carried by us on 30th June found out that out of this, 23.1% (269 person) are

aged more than 35. The organisation of this village consists of the Penghulu, Ketua Kampung,

Jawatankuasa Kemajuan dan Keselamatan Kampung(JKKK) followed by the community.

Economy

The majority of people in Kampung Sadong Jaya are farmers. Other occupations

include labourers in construction sites, fishermen and government servants. The common

plantations include coconut, cocoa, corn, pineapple and banana. Most of the farmers sell their

products such as coconut either directly to the shops or through Pertubuhan Peladang Sarawak.

Some bring the products to be sold at pasar rani.

4

Pusat KhidmAt Maktuiuat Akadelrcil, UNiVERSITI MALAYSIA SARAWAK

Basic amenities

Kampung Sadong Jaya is well equipped with basic amenities such as treated water and

electrical supply since the early 1990's. The houses are also supplied with phone lines. The

roads in this village are tar roads. The presence of rented vans as well as own transportation

enable the villagers to commute to the surrounding areas. Other facilities in this village include

public phones, post office, police station, common hall, registration office and primary school.

Health facilities

The health facilities in Kampung Sadong Jaya is mainly provided by the Klinik

Kesihatan Sadong Jaya which is situated 3 km away with more serious cases being referred to

the Sarawak General Hospital. The organization of this health clinic consists of a health

officer (Bahagian), a medical officer (clinic), two medical assistants, a lab technologist, six

community nurses, an assistant pharmacist, a public health assistant, two health attendants and

a driver. The services offered by this clinic include out patient care, antenatal care, post natal

care, dental care, environmental health (KAS), health education (HE), lab facilities, mental

care, village health team (VHT), tuberculosis control program (TBCP), immunization and

school health (SH). These services are offered according to a schedule.

5

Pegawai Kesihatan Bahagian

Pegawai Perubatan

Pembantu Perubatan 1

Pembantu Perubatan

Pembantu Perubatan 2

im

Juruteknologi Makmal

Perubatan

Pembantu farmasi

Jururawat Masyarakat (JM) Kanan

TM

Pembantu Kesihatan Awam

Altenden Lelaki Attenden Perempuan

im

Pemandu Kenderaan Bernrotor

CARTA ORGANISASI KLINIK KESIHATAN SADONG JAYA

6

CHAPTER II

STATEMENT OF PROBLEM AND LITERATURE REVIEW

2.1 Statement of problem

During our first visit to Kampung Sadong Jaya on 19th June 2004, the villagers did not

complaint of any health problems. However, upon direct questioning, we found out that their

diet contain significantly high cholesterol food such as rendang, nasi lemak sambal udang,

ikon bills, coconut milk containing food, eggs and beef. This pattern of diet is an important risk

factor for the development of coronary heart disease. Therefore, we proposed to do a study on

the knowledge, attitude and practice of hypercholesterolaemia as a risk factor for coronary

heart disease in the age group 35 years old and above in this village and were accepted by

them.

Even though, Kampung Sadong Jaya is situated in a rural setting, it still faces the effects

of urbanization of the surrounding area. It is therefore widely exposed to the risk factors of

diseases of the modern society of which coronary heart disease is the major one. This is mainly

due the changes in diet which leads to nutritional disorders such, as hypercholestrolaemia.

Despite such changes, the villagers still lack in knowledge regarding hypercholesterolaemia

which in turn affect their attitude and behaviour towards it.

We aim our study on the sample population aged 35 years old and above because the

major increase in hypercholestrolaemia is noted to begin at this age especially in men.

Furthermore, at this age the effects of hypercholestrolaemia as a risk factor for coronary heart

disease are widely seen. Since hypercholestrolaemia and coronary heart disease prevail as the

7

most significant cause of premature deaths in middle aged men (WHO, 1996), it is therefore a

move in the correct direction to target this age group as our study subject.

During the discussion with the villagers, they also revealed the lack of knowledge on

hypercholestrolaemia as a risk factor for coronary heart disease. Lack of knowledge affects their

attitude and practice towards this risk factor. By doing this study, we can measure the level of

awareness among the villagers regarding hypercholestrolaemia which is an important modifiable

risk factor of coronary heart disease.

Furthermore, most of the studies regarding hypercholesterolaemia are carried out in

urban areas because we generally fail to realize that these risk factors are also present in the rural

population. According to the villagers, although there is an outpatient department that deals with

problems of hypercholesterolaemia but programs involving educational and awareness-raising

intervention are seldom carried out in their village.

Hence, by carrying out this research we aim to identify the knowledge, attitude and

practice regarding hypercholesterolaemia as a risk factor of coronary heart disease so that early

health screening and health education intervention program can " be done to decrease the

morbidity and mortality due to coronary heart disease.

8

PROBLEM NETWORK

Hereditary

'I! ___ ____I__

Low Household

Income

N

-------------------------------------------------------------

Ethnic Gender

I ---------------------------

TT

Behaviour 0

cholesterol

N

Low Educational Level

Lack of Knowledge

Negative Attitude

Obesity

-I --------------------------- f------------- r-

Age

Educational Diagnosis

Behaviour Diagnosis

-----------------------------------

T Prevalence of Hypercholesterolaemia

Wrong Priority

Epidemiology Diagnosis

2.2 Literature review

Cholesterol is a substance that occurs naturally and is needed for our body to function

properly. Cholesterol is a soft, waxy substance found among the lipids in the bloodstream and in

all the body's cells. It is an important part of a healthy body because it is used to form cell

Membranes, some hormones, and other needed tissues. Cholesterol circulates in the blood stream.

it is an essential molecule for the human body. Cholesterol is a molecule from which hormones

land steroids are made. It is also used to maintain nerve cells.

Cholesterol is found in animal sources of food. It is not found in plants. Cholesterol is also

p form of fat found in egg yolks, meat, poultry, seafood and dairy products. Foods from plants

such as fiuits, vegetables, vegetable oils, grains, cereals, nuts and seeds may contain fat but not

cholesterol. Approximately 80 per cent of the cholesterol in the blood is manufactured by the liver.

The remaining 20 per cent comes from the foods we eat. Although many foods may be labelled

cholesterol free" or "cholesterol reduced", the liver manufactures lipoproteins from all fats we

consumed, therefore it is important to concentrate more on reducing the total fat consumption, than

on merely limited cholesterol consumption.

Cholesterol and other fats are not able to dissolve in the blood, and so are transported to

, and from the cells in the form of lipoproteins. Lipoproteins are a combination of fat (lipids) and

; proteins. There are several kinds of lipoproteins. But the ones to be most concerned about are low-

density lipoprotein (LDL) and high-density lipoprotein (HDL). Low-density lipoprotein (LDL) is

the major cholesterol carrier in the blood. Normal levels of LDL are essential for cell repair and

growth, however high levels of LDL in the blood are associated with the development of

atherosclerosis, and therefore coronary artery disease, heart attacks and strokes. This is why LDL

10

cholesterol is often referred to as the "bad" cholesterol. " Lower levels of LDL cholesterol reflect a

lower risk of heart disease. High-density lipoprotein or HDL has a higher protein-to-fat ratio than

. DL and it makes up about one-third to one-fourth of the blood cholesterol. HDL is commonly

referred to as the "good cholesterol" because it helps to carry excess LDL away from the walls of

, the blood vessels and back to the liver for excretion (Johnson et al, 1993). Research suggests that

high levels of HDL may protect the heart against atherosclerosis, and may even remove cholesterol

from atherosclerotic plaques and slow down their growth.

The desirable total cholesterol level is below 5.2 mmol/L. Borderline high is when the

(cholesterol level is between 5.2 to 6.2 mmol/L and it is considered high when more than

6.2mmol/L. The desired HDL cholesterol level is more than 0.9mmol/L. Ideal LDL cholesterol

! level is less than 3.5 mmol/L, borderline high is in between 3.5 to 3.9 mmol/L and high is more

than 4.0 mmol/L. Ideal triglycerides level is less than 2.0 mmol/L, borderline high is between 2.0

, to 3.0 mmol/L and high is more than 3.0 mmol/L (WHO Expert Committee, 1996).

Hypercholesterolaemia is very much influenced by lifestyle factors such as diet, exercise

and stress levels. On the other hand, it is also influenced by patients' knowledge, attitude, practice

and the intercorrelation between these factors.

Obesity, which generally results from eating a diet high in fat, can also lead to elevated

I cholesterol levels in the blood. This is because obesity itself leads the body to produce excessive

amounts of cholesterol. Being overweight is a risk factor for heart disease. It also tends to increase

the cholesterol. Losing weight can help lower LDL and total cholesterol levels, as well as raise

HDL and lower triglyceride levels (Neaton, 1992).

11