390

Chapter 61

Cholesterol

Overview

• Although cholesterol is largely a product of animal metabolism, it is found in small

amounts in plants.
• Cholesterol is distributed into 3 body pools, and not all CH molecules are equally
accessible to metabolic interactions or to exchange.
• Bile is the major route for cholesterol elimination from the body.
• Acetyl-CoA is the source of all carbon atoms in cholesterol.
• HMG-CoA reductase is the rate-limiting enzyme in cholesterol biosynthesis.
• Glucagon and cortisol, hormones typically elevated during starvation, inhibit hepatic
CH biosynthesis.
• Insulin and thyroid hormones tend to enhance the hepatic clearance of CH from the
circulation, as well as hepatic synthesis of CH.
• The cholesterol biosynthetic scheme in plants seems to end at squalene.
• The cyclopentanoperhydrophenanthrene nucleus of CH is common to all animal steroids.
• The liver synthesizes more cholesterol than any other organ.
• Cholesterol, coprostanol, and cholestanol are generally the primary sterols found
in feces.

Cholesterol (CH; Gr. "Chole" - bile, "stereos" -
solid) is essential for the survival of all animals,
where it becomes a structural component
of membranes, and the parent molecule that
gives rise to other important steroids (Fig.
61-1). The greater part of CH arises from de
novo biosynthesis, particularly in herbivores.
Indeed, virtually all nucleated eukaryotic cells
have the capacity to synthesize CH, but the
quantitatively most important are hepatocytes,
and, to a lesser extent, intestinal mucosal
cells. Cholesterol is largely a product of animal
metabolism (not plant or microbial), and occurs
therefore in foods of animal origin such as liver,
meat, milk, and egg yolk (a particularly rich
source). In carnivores and omnivores, about
Copyright © 2015 Elsevier Inc. All rights reserved.
one-third of the body CH pool is generally
provided through the diet.
More than 250 steroids (phytosterols) have
been described in plants, but of these β-sitos-
terol (otherwise known as β-prostate), which
differs from CH by an added ethyl grouping
at position 24, is the most common (Fig. 61-2).
Plants contain small amounts of CH, both free
and esterified, where it is a component of
plant membranes. While CH averages about
0.05 gm/kg total lipid in plants, it is much
higher in animals. Although the total CH pool
varies minimally in normal adult animals, tissue
contents can vary from about 0.5 gm/kg muscle
tissue, to about 15 gm/kg brain tissue.The
average CH content is about 1.4 gm/kg tissue

for the body as a whole. Thus, a 35 kg mammal
contains about 50 gm of CH.
In general, CH is distributed into three body
pools, and not all are equally accessible to
metabolic interactions, or to exchange with CH
carried in blood:
1) Rapidly miscible pool -- Cholesterol
absorbed from the diet, and CH in blood, the
small intestine, lung, liver, and spleen.
2) Slowly exchangeable pool -- A portion of
CH in adipocytes, skeletal muscle, and skin.
3) Slowly miscible, or nonexchangeable pool
54 Chapter 61 391
Figure 61-1
--Cholesterol present in brain and bone, and
some in skin, skeletal muscle, and adipo-
cytes.
Dietary CH usually takes several days to
equilibrate with that in plasma, and several
weeks to equilibrate with that in tissues.
Hepatic turnover is rapid compared with the
half-life of total body CH, which is several
weeks. Cholesterol in plasma and that in liver
usually equilibrate in a matter of hours.
Wide variations in the plasma CH concen-
trations of animals have been reported (e.g.,
Figure 61-2
392 Cholesterol
horses 75-150 mg/dl, cows 80-120, goats 80-130,
sheep 52-76, pigs 36-54, dogs 125-250, and
cats 95-130). The greater part of plasma CH
(80-90%) is usually esterified with unsaturated
fatty acids (Chapter 60). It is transported in
plasma lipoproteins, with the highest propor-
tion found in low-density lipoprotein (LDL),
which is formed from very low-density lipopro-
tein (VLDL) and intermediate-density lipopro-
tein (IDL) in plasma (see Chapter 65). However,
under conditions where VLDL are quantita-
tively predominant (e.g., ponies), increased
proportions of CH will continue to reside in
Figure 61-3
this fraction. Ultimately, LDL are removed from
plasma, mainly by the liver (see Chapters 65,
66, and 67).
There are several pathways for removal of
CH from the body; through the sloughing of
oily secretions and cells from the skin, through
desquamation of cells from the stomach, small
intestine, and colon, and through the movement
of CH into pancreatic, gastric, intestinal, and
biliary canalicular secretions. Cholesterol can
also be metabolized to other steroids, such
as bile acids and steroid hormones, which in
turn are excreted from the body either through
bile (the bile acids), or urine (the glucuronide
conjugates of steroid hormones). Of these
various routes, hepatic conversion of CH to
bile acids, and secretion of both bile acids and
CH directly into bile are of greatest quantita-
tive importance (see Chapter 62).
Dietary CH in dogs is normally less than
one-half of total body CH synthesis per day, and
the amount used in steroid hormone biosyn-
thesis is only 10% of that used in bile acid
biosynthesis. Although bile acid synthesis and
excretion by the liver can potentially be a
significant way in which to remove CH from
the body, this route of elimination is normally
negated through extensive BA reabsorption
in the ileum. Biliary CH excretion is, however,
a significant way in which the body rids itself
of CH, for approximately 60% of CH normally
present in the small intestine at any one time is
that derived from bile (Fig. 61-2). The amount of
CH absorbed from the intestine (both biliary and
dietary CH), is dependent upon several factors,
including the amount of dietary saturated fat
which tends to increase intestinal CH absorp-
tion.
Cholesterol Biosynthesis
Acetyl-CoA is the source of all carbon atoms
in CH, with the overall reaction sequence
described as follows:
[ ]
18 Acetyl-CoA + 18 ATP + 16 NADPH
+ 4 O2 —> Cholesterol + 9 CO2 +
16 NADP+ + 18 ADP + 18 Pi
Cholesterol biosynthesis is generally subdi-
vided into four stages:
Stage 1. Formation of mevalonate,
 54 Chapter 61 393

The four stages of cholesterol biosynthesis are

shown (formation of mevalonate, conversion
to isoprenoids, condensation to squalene, and
conversion to cholesterol). Stage one pos-
sesses the rate-limiting reaction, conversion of
HMG-CoA to mevalonate. This reaction is cata-
lyzed by HMG-CoA reductase, an important
enzyme known to be regulated by a number of
endogenous and exogenous factors. It should
be recognized that insulin and thyroxine not
only increase hepatic cholesterol biosynthe-
sis, but they also enhance liver clearance of
cholesterol from the circulation by stimulating
hepatic LDL receptor synthesis and activity
(see Chapters 66 & 67). In diabetes mellitus
(DM) and hypothyroidism, plasma cholesterol
levels rise.

Figure 61-4
394 Cholesterol
Stage 2. Conversion of mevalonate to
active isoprenoids,
Stage 3. Condensation of isoprenoids to
squalene, and
Stage 4. Conversion of squalene to CH
(Fig. 61-4).
In stage 1, HMG-CoA, a C6 intermediate, is
formed by sequential condensation of 3 acetyl-
CoA molecules. This cytoplasmic process
follows the same reaction sequence described
for the biosynthesis of ketone bodies in mito-
chondria (see Chapter 71). Next, HMG-CoA is
converted to mevalonate via reduction by 2
NADPH, catalyzed by the microsomal enzyme,
HMG-CoA reductase. This rate-limiting step in
cholesterol biosynthesis is inhibited by meval-
onate, the immediate product, by CH, the main
product of the pathway, by certain fungal
metabolites (i.e., the cholesterol-lowering
"statin" drugs), and by starvation. Glucagon
and cortisol, hormones typically elevated
during starvation, depress hepatic CH biosyn-
thesis, whereas insulin and thyroid hormones
elevate it. Opposing effects of insulin and
glucagon in the liver are mediated by the
dephosphorylation and phosphorylation of
HMG-CoA reductase, respectively, whereas
the effects of thyroxin and cortisol are mediated
by the induction and repression of HMG-CoA
reductase biosynthesis. Although CH feeding
decreases hepatic CH biosynthesis, increased
dietary carbohydrate or triglyceride intake
augments it primarily by increasing availability
of acetyl-CoA and NADPH. The pathways that
supply these substrates from carbohydrate in
the liver, particularly glycolysis (see Chapters
23-27), the pyruvate dehydrogenase reaction
(see Chapter 27), and the NADPH-generating
steps of the hexose monophosphate shunt (see
Chapter 28), are activated by insulin.
In stage 2, formation of activated isoprenoid
units from mevalonate requires 3 ATP, and
results in the loss of H2O and CO2. These isopre-
noid units now become building blocks not only
of the basic steroid skeleton, but also of other
derivatives, such as dolichol and ubiquinone
(coenzyme Q; see Chapter 36).
In stage 3, six isoprenoid units condense in
a series of 3 reactions to form the interme-
diate, squalene. NADPH is required in the final
condensation reaction. Plant sterols (phytos-
terols like the phytoestrogens, the auxins
and giberellins (steroid-like plant hormones),
and the fat-soluble vitamins), are polypre-
noids largely derived from mevalonate and/
or squalene. Plant sterols differ from animal
sterols in the nature of their side-chains, and
generally cannot be utilized by animal cells.
Less than 5% of dietary plant sterols are
normally absorbed by the mammalian digestive
tract (compared to 30% of available CH). The
liver normally clears plant sterols efficiently
from portal blood, and excretes them into bile.
In stage 4, squalene is first converted to an
oxide, and then to lanosterol, which possesses
the C17 cyclopentanoperhydrophenanthrene
nucleus common to all animal steroids.
Formation of CH from lanosterol takes place
in the endoplasmic reticulum, and involves
changes in the steroid nucleus and side chain.
Five steps are thought to be involved, in which
three methyl groups are released from the ring
as CO2, and a double bond in the side chain is
reduced. The exact order in which these steps
occur is not known with certainty.
Hepatic intermediates from squalene to CH
are attached to a sterol carrier protein, which
binds sterols and other insoluble lipids, allowing
them to react in the soluble cell interior. This
protein is also thought to act in the conversion
of CH to bile acids (see Chapter 62), and in the
formation of membranes and lipoproteins (e.g.,
VLDL and high-density lipoprotein (HDL)).
Following movement of CH into bile, and then
into the intestine, coprostanol is formed via
bacterial reduction of the double bond of CH
between C5 and C6. Cholestanol, a precursor
to coprostanol, is formed in the liver as well as

in the intestinal tract, and these two stanols,
together with CH, normally become primary
fecal sterols.
Abnormalities in the
Plasma Cholesterol Concentration
Animals that exhibit hypo- or hypercholeste-
rolemia most likely have a dietary or endocrine
abnormality, a drug-induced disorder, kidney
disease, or an intestinal, pancreatic or hepato-
biliary abnormality. Hypocholesterolemia may
occur with hyperthyroidism, by the adminis-
tration of drugs that reduce endogenous CH
biosynthesis or its absorption from the intestine,
or by intestinal diseases which adversely affect
bile acid and CH absorption. When intes-
tinal CH absorption is compromised, increased
amounts of CH are used by the liver for bile
acid biosynthesis, thus lowering the plasma
CH concentration (see Chapters 62, 66, and
67). Hypercholesterolemia in animals is usually
recognized as a secondary hyperlipidemia,
most often associated with decreased hepatic
removal of LDL from the circulation, as seen in
hypothyroidism, hypersomatotropism, diabetes
mellitus, Cushing's disease or syndrome,
and various forms of hepatobiliary disease.
Additionally, ultra-high fat diets, drug-induced
disorders (e.g., megestrol acetate administra-
tion to cats), pancreatitis, and kidney disease
are also associated with hypercholesterolemia
in animals (see Chapters 63 and 67).
In summary, CH is a structural component of
cell membranes, adding to membrane rigidity,
but varies in concentration from 0-40% of
total membrane lipid. Although virtually all
nucleated eukaryotic cells can synthesize
CH, hepatocytes do so to the largest degree.
HMG-CoA reductase is the rate-limiting enzyme
in CH biosynthesis, whose activity is controlled
via several endogenous and exogenous
agents. Cholesterol can be metabolized to
other steroids, such as bile acids and steroid
hormones, which maintain considerable physi-
ologic activity. Plasma CH concentrations vary
54 Chapter 61 395
among animal species, and hypercholester-
olemia is usually recognized as a secondary
hyperlipidemia (see Chapter 67). It is normally
secreted into bile, not urine, and usually exits
the body through feces and the sloughing of
oily secretions and cells from the skin.
OBJECTIVES
• Identify the primary sources of CH for animals,
show how tissue contents vary, and how plasma
concentrations differ between animal species.
• Explain how CH is absorbed by the intestinal
tract, transported in plasma, and excreted from
the body.
• Distinguish each of the four stages of CH bio-
synthesis.
• Identify the rate-limiting reaction in CH biosyn-
thesis, and discuss its endogenous and exog-
enous control.
• Recognize common causes of hypo- and hyper-
cholesterolemia, and explain why hypercho-
lesterolemia is usually viewed as a secondary
hyperlipidemia (see Chapter 67).
• Explain the relationship of CH to bile acid metab-
olism (see Chapter 62).
• Compare plant sterol to CH absorption from the
gut, and clearance from the body.
• Provide an accounting of the relative amounts
of CH normally excreted into bile, converted to
bile acids or used in the biosynthesis of steroid
hormones.
• Understand what is meant by "good" and "bad"
CH (see Chapter 66).
• Recognize the fecal forms of cholesterol.
• Understand structural differences between cho-
lesterol and β-sitosterol.
• Explain why and how starvation reduces hepatic
cholesterol biosynthesis, yet increased dietary
carbohydrate and/or triglyceride intake increas-
es it.
• Understand why and how dietary saturated fat
intake, or trans-unsaturated fat intake, increas-
es the plasma CH concentration.
• Recognize the difference between CH and CE,
and discuss how essential UFAs are conserved.
396 Cholesterol

QUESTIONS
6. Which one of the following is formed from
1. Cholesterol present in which one of the
cholesterol in the intestine via bacterial
following organs becomes part of the
reduction?
rapidly-miscible cholesterol pool?
a. Coprostanol
a. Skeletal muscle
b. Cholecalciferol
b. Skin
c. Cortisol
c. Adipocytes
d. Lanosterol
d. Brain
e. Mevalonate
e. Liver

7. Hypocholesterolemia is best
2. The greater part of cholesterol in
associated with:
plasma is:
a. Diabetes mellitus.
a. Associated with VLDL.
b. Cushing's disease.
b. Esterified with unsaturated fatty acids.
c. Hyperthyroidism.
c. Bound to albumin.
d. Kidney disease.
d. Found as free cholesterol in circulating
e. Biliary obstruction.
lipoproteins.
e. Bound to steroid hormones.
8. The primary phytosterol of plants is:
3. The primary excretory route for a. Cholesterol ester (CE).
cholesterol is: b. Squalene.
a. Bile. c. Lanosterol.
b. Urine. d. Cholestanol.
c. Expired air. e. β-Sitosterol.
d. Sweat.
e. Hair loss. 9. Hypercholesterolemia in mammals:
a. Is not recognized, and therefore not
4. HMG-CoA reductase, the rate-limiting important.
enzyme in cholesterol biosynthesis, is b. Is usually a secondary hyperlipidemia.
inhibited by: c. Is generally a result of hyperthyroidism.
a. Insulin. d. Causes lipemia.
b. Thyroid hormones. e. Rarely occurs in patients with diabetes
c. Squalene. mellitus.
d. Cholesterol.
e. Triglyceride ingestion. 10. All carbon atoms in CH can 11. d
be derived from: 10. c
5. Select the TRUE statement regarding a. Palmitate.
b. NADPH.
9. b
plants:
a. Plants, unlike animals, do not contain c. Acetyl-CoA. 8. e
cholesterol. d. Deoxycholate. 7. c
b. Less than 5% of most dietary plant e. HMG-CoA reductase.
6. a
sterols (phytosterols) are normally
absorbed by the mammalian digestive 11. Which cell type is associated with
5. b
tract. the bulk of CH biosynthesis? 4. d
c. Since herbivores cannot synthesize choles- a. Neuron
terol, they derive all of their needs
3. a
b. Adipocyte
for this steroid directly from plants. c. Testicular Leydig cell 2. b
d. β-Sitosterol, a plant steroid, is what d. Hepatocyte 1. e
animals use to synthesize cholesterol. e. Skeletal myocyte
e. Plants and animals contain about the
same amount of cholesterol per gram.
ANSWERS