Cholesterol: A Numbers Game

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So you just got the results of your blood test, and your doctor is concerned. He says your “bad” cholesterol is zooming up and the “good” one doesn’t look that great, either.
He prescribes a cholesterol-lowering drug, something with “or” at the end—Lipitor? Crestor?—and tells you to lose weight, step up the exercise and say bye-bye to the blue-cheese burgers.
It all sounds so grim—and confusing. Is a lifetime of prescription drugs the only answer? Couldn’t you just eat more oatmeal instead? And what do all those numbers mean, anyway? Just how worried should you be?
If you’re facing such questions, join the club. According to 2008 figures from the American Heart Association, more than 106 million Americans ages 20 and older have high cholesterol—a major risk factor for heart disease, heart attack and stroke.

One Measure of Risk
With heart disease holding the No. 1 spot as the leading cause of death in the United States, this cholesterol stuff cannot be taken lightly. But don’t hit the panic button just yet. Cholesterol is only one measure of risk and doesn’t necessarily mean you’re next in line for a heart attack, says Maxine Barish-Wreden, M.D., co-medical director for women’s heart disease prevention at the Sutter Heart & Vascular Institute in Sacramento.
“If someone is generally really healthy, with no other risk factors, then the cholesterol level may not be that great a predictor of future heart attack or stroke,” says Barish-Wreden. “Taken by themselves, some risk factors are usually worse than having high cholesterol.”
Cigarette smoking, diabetes and obesity top the list, she says. Other risk factors include a lousy diet, lack of exercise, high blood pressure and genetics (thanks, Mom and Dad).
The bottom line: The more risk factors a person has, the more important cholesterol becomes.
“All of these risk factors, when added up, give you an estimate of someone’s risk of having a heart attack over the next 10 years,” says Barish-Wreden. The goal, she says, is to reduce as many risk factors as possible—and since cholesterol is something you can actually do something about, it’s understandable that your doctor is giving you 30 lashes for not dropping the excess 30 pounds or refusing to take your meds.

“A Lifelong Thing”
Losing weight and taking cholesterol-lowering statin drugs are just a few of the weapons “John” (not his real name) has used in his war against cholesterol. For years, he avoided being tested for fear of gett-ing bad news—high cholesterol runs in his family—and at 51, his fears were confirmed: His total blood cholesterol was at 325. (The danger zone, according to standard guidelines, starts at 200.)
“I was stunned when I got the 325 report,” says John. “That’s sort of off the charts for cholesterol.” The rest of his lipid panel didn’t look good, either: His LDL (the “bad” cholesterol) was in the very high-risk zone of 236, and his triglycerides were borderline high at 189. His HDL (the “good” cholesterol) wasn’t bad but could have been better.
“It was a real wake-up call,” says John. “I was afraid of a heart attack.” His age added to his fears, he says. “Once you turn 50, you start thinking about these things.”
But John initially wasn’t comfortable with the idea of taking the statin prescribed by his doctor. “I didn’t want to take the meds because I knew it would be a lifelong thing,” he says. Instead, he embarked on his own plan: a super-low-fat, high-fiber diet, plus aerobic workouts and weight training. In just six months, he shed some 30 pounds and his cholesterol plummeted, too: His “total” number sailed from 325 to 242 and his LDL dropped from 236 to 147.
But over time, John had trouble maintaining the all-important ratio between LDL and HDL—which, according to experts, is a more telling barometer of one’s risk than total cholesterol alone. After further experiments with niacin and a low-carb diet, which helped but still didn’t quite cut it, he finally followed doctor’s orders and tried Mevacor (lovastatin).
“It’s worked well for me,” says John, adding that he felt comfortable with Mevacor because it’s one of the early statins and has been well tested. He’s also doing his bit by keeping his weight down with a low-carb diet and exercise.
Numberswise, John has had his ups and downs. But at 62, after 11 years of battling high cholesterol, he’s learned to be philosophical.
“When you get into a lifelong thing like this, you need to keep in mind it’s not necessarily going to be a steady road,” he says. “You’re not always going to be able to be an ‘A’ student. But you’ve gotta keep plugging away.”

Should Everyone Take Statins?
Like John, many patients who show up with high cholesterol will walk out of the doctor’s office with a script for statins. And that’s exactly as it should be, according to Scott Baron, M.D., an interventional cardiologist with the Mercy Heart & Vascular Institute.
“I’m very proactive about statins,” he says. “When you’re a cardiologist, looking at heart arteries all the time, you get an interesting perspective you may not get otherwise.” Baron says he doesn’t know a single card-iologist who isn’t taking statins, including those with low cholesterol.
Statins are well tolerated by most, Baron says, and do such a good job of lowering LDL that taking them can mean the difference between life and death. “The difference between people who have cardiac ‘events’ and those who don’t is their cholesterol level, so people need to be serious about getting it down,” he says. While all the numbers count, LDL is the one that’s most predictive of outcomes, “so if you’re gonna pick out one piece of the pie,” says Baron, “worry about your LDL.”
Statins have been shown to have the most dramatic cholesterol-lowering effects, reducing LDL by up to 55 percent, according to the Natural Medicines Comprehensive Database, whereas HDL and triglyceride numbers can be better helped by natural supplements—namely, niacin and fish oil. According to the database, niacin has been shown to raise HDL by 35 percent (compared to statins at 6 to 14 percent), and both niacin and fish oil are effective in reducing triglycerides by 20 to 50 percent. The upshot? While statins alone may work for some, a combination of therapies works for others.
Whatever the therapy, possible side effects must be considered. Niacin is known to cause flushing and hot, prickly skin. Statins can cause muscle aches and pains in a significant number of people, according to Barish-Wreden. Liver inflammation, while infrequent, also can occur, making regular monitoring important. Left unchecked, a severe increase in liver enzymes may lead to permanent liver damage.
Another unwelcome side effect to statins: the cost.
“The real question is the economic burden to society if we start widely prescribing statins,” says Stanley Chew, M.D., a Sacramento internist in private practice. The question—should everyone take statins?—has been a hot topic since the release of last year’s “Jupiter” study, which targeted some 18,000 people who did not have high cholesterol but did have elevated levels of high-sensitivity C-reactive protein, or hs-CRP, an inflammation marker linked to cardiovascular risk. While it’s easy to be queasy when you learn the study was funded by AstraZeneca, maker of Crestor (the medication used in the trial), the findings were compelling: Risk of heart attack or stroke was cut by almost half and death rates were reduced by 20 percent for those who took statins.
“Of course, this doesn’t mean we should put everyone on statins,” but it does shine a light on the role CRP plays in the heart disease story, says Chew, who had been routinely testing his patients’ CRP levels even before the study came out. While the regular CRP test is nonspecific, pointing to inflammation anywhere in the body, the hs-CRP targets a person’s risk of heart disease. It can be a valuable add-on test as doctors assess a patient’s risk factors and weigh treatment options, including statins.

The Natural Way
But not all patients are hunky-dory with the idea of taking meds. Pam Cameron is one of them.
“I’m not a pill person,” says Cameron, whose total cholesterol tested around 285 a few years ago, prompting her doctor to suggest a statin.
No thanks, said the downtown resident. But she knew she had to do something because her blood sugar levels were climbing right along with the cholesterol, indicating pre-diabetes. Motivation came easily: Her mother died of diabetes-related complications in her 70s. Cameron, now 64, chose to avoid that fate.
After doing some research, Cameron decided she might be sensitive to grains and sugar. After cutting out those culprits and switching to a diet rich in proteins, salads, vegetables and fruit—plus continuing her already-in-place exercise regimen (“I’ve always done a lot of walking”)—her blood glucose came way down and so did her cholesterol. Both her total and LDL numbers have dropped by some 60 points, her triglycerides have tumbled and her HDL went from 47 to 75.
She’s also shed about 25 pounds—an important piece of the cholesterol pie. With the number of obese and overweight Americans approaching 64 percent of the population, experts emphasize that one of the best things we can do to combat cholesterol (and other medical ills) is to peel off the pounds.
“Heart disease is largely preventable,” stresses Barish-Wreden, adding that lifestyle changes are always her first recommendation for high-cholesterol patients. The key points: Maintain a lean weight, get regular exercise, and eat a diet low in saturated fats and high in lean proteins, fruits, veggies and fiber. If you need to add a pharmaceutical product, she says, “you can always do it low dose, meaning lower risks.”
Those who can’t physically tolerate or just plain don’t want to take pharmaceuticals often can be helped by natural supplements, adds Barish-Wreden, an integrative-medicine expert (she’s a medical director at Sutter Sacramento’s Downtown Integrative Health Care program).
She’s especially fond of fish oil for lowering triglycerides, as it offers an anti-inflammatory effect. But check the label, she warns: An omega-3 fatty acid fish oil with 300 to 600 milligrams of EPA and DHA (essential fatty acids), taken daily, is recommended.
Other natural supplements that have been shown to reduce cholesterol include artichoke extract, plant sterols and stanols (which occur naturally in many foods—even granola bars), high-fiber foods (especially blond psyllium and oat bran) and soy. Red yeast rice is another effective cholesterol-fighter, but because some products contain a natural form of the prescription drug lovastatin (Mevacor), its use is controversial. Barish-Wreden suggests a low-dose pharmaceutical may be a better choice “because with herbal stuff off the shelf, you never know what you’re getting.” Consumers who want to try red yeast rice are advised to get a product that’s been reviewed (check consumerlab.com), have their liver monitored and—as always—discuss it with their doctor.

Individual Approach
Whatever path is chosen, treatment should be tailored to the individual, says Chew, taking into account the all-important risks/benefits question and looking beyond a patient’s cholesterol numbers to what he calls the “the total package”—age, gender, family history and all the rest.
And one more thing: Though men tend to develop cholesterol problems at an earlier age (their 40s and 50s), women aren’t off the hook. Barish-Wreden says women’s problems just kick in later, after menopause, when the heart-protective benefits of estrogen drop off.

Lose weight, lower cholesterol?
Will dropping pounds cause your cholesterol to drop? The quick answer: In most cases, yes (though it depends on a person’s genetics).
But there’s a caveat: While losing weight can reduce your LDL, it can reduce your HDL, too.
Exercise can help to fix that, according to Maxine Barish-Wreden, M.D., co-medical director for women’s heart disease prevention at the Sutter Heart & Vascular Institute in Sacramento. “Exercise should raise, or at least maintain, your HDL,” Barish-Wreden says. Exercise also can help to drop your LDL further, she notes, and the combination of weight loss and exercise also should lower your triglycerides.
But what happens when you maintain your weight loss? Will cholesterol numbers jump back up?
Again, it goes back to exercise. “If you continue to exercise, maintain a healthy weight and eat a healthy diet,” Barish-Wreden explains, “your cholesterol should remain pretty normal, too.”

How low can you go?—
Can cholesterol ever be too low?
“Too low is usually not an issue,” says Scott Baron, M.D., an interventional cardiologist with Mercy Heart & Vascular Institute. Low cholesterol usually is a good thing, reducing one’s risk of heart disease.
Sometimes, however, low cholesterol can point to underlying disease, including cancer, says Baron. Depression and anxiety also are associated with low numbers.
If you’re concerned about your numbers, ask your doctor. What’s normal for you may be different from what’s normal for someone else.

Cholesterol-fighting foods
If you join the oatmeal-eating club, will your cholesterol numbers drop? You bet, say the experts at mayoclinic.com. Here’s their list of the top five foods for cholesterol reduction.

1. Sow your wild oats. Oatmeal and oat bran are excellent sources of soluble fiber, also found in kidney beans, apples, barley and other foods. Guidelines: Eat 10 or more grams of soluble fiber a day. (A bowl of cooked oatmeal equals about six grams; add some fresh fruit and you should have around 10.)
2. Go nuts for nuts. Nuts may be rich in calories, but they’re also rich in polyunsaturated fatty acids, a powerful cholesterol reducer. To avoid weight gain while you lose cholesterol, eat only a handful (no more than two ounces) of nuts a day. Walnuts and almonds are tops.
3. Make friends with fish. Seafood lovers shouldn’t have any trouble with this: Just eat at least two servings a week of fish high in omega-3 fatty acids, which not only reduce cholesterol but blood pressure, too. Albacore tuna, salmon, mackerel, herring, lake trout and sardines are the best sources. If you’re not fond of fish, try a supplement or other sources of omega-3s, such as ground flaxseed and canola oil.
4. Choose olive oil. Loaded with antioxidants, olive oil helps to lower LDL (“bad”) cholesterol. Dunk your bread in it, mix it with vinegar for a salad dressing or sauté veggies in it, aiming for two tablespoons a day. But avoid the “light” variety: It’s usually more heavily processed and lighter in antioxidants.
5. Take a stand with stanols and sterols. Found in plants, stanols and sterols help to keep cholesterol from being absorbed. But where can you find them? A surprising number of foods are fortified with them, including margarine, orange juice, dairy products—even chocolate. For full benefits, eat at least two grams of the stuff every day.

Want to calculate your own risk?
Check out the Framingham risk assessment tool, which uses information from the Framingham Heart Study (a famous, long-term study that looks at cardiovascular risk factors) to estimate your chances of
having a heart attack in the next 10 years. Go to http://hp2010.nhlbihin.net/atpiii/calculator.asp and have your lipid report handy: You’ll need to plug in your HDL and total cholesterol numbers.

Cholesterol Facts
* Cholesterol itself isn’t bad; in fact, we need it to stay healthy.
* Children aren’t immune to high cholesterol. Atherosclerosis (arterial plaque buildup) or its precursors begin in youth.
* You can’t judge a book by its cover: Thin people can have high cholesterol, too.
* Cholesterol checks should begin at age 20—not middle age.
* Most cholesterol is produced by your liver.
* High cholesterol is asymptomatic.
Source: The American Heart Association website, americanheart.org

By the Numbers
If someone asks you how high your cholesterol is, you need to ask which one, as there are four numbers to consider: total cholesterol, triglycerides, and those confusing “good” and “bad” cholesterols, HDL and LDL, respectively.
But what does it all mean? “The numbers can help us to predict risk of a future event: heart attack or stroke,” explains Stanley Chew, M.D., a Sacramento internist in private practice. Doctors look not just at the total cholesterol number, but the delicate interplay between them (your HDL/LDL ratio, for example), plus other factors, to assess risk.
Some experts, Chew adds, predict guidelines for what’s considered “optimal” cholesterol levels soon will be more stringent, reflecting a more aggressive stance. (An LDL of 70, for example, may replace the current benchmark of 100.) But for now, the numbers below reflect standard guidelines, culled from the American Heart Association website, americanheart.org. (Note: All numbers reported are mg/dL, meaning milligrams per deciliter of blood.)

Total Blood (or Serum) Cholesterol Level
Desirable: Less than 200
Borderline High Risk: 200–239
High Risk: 240-plus

LDL (Low-density lipoprotein, the “bad” cholesterol)—Wondering if you’re at high risk of heart attack or stroke? Look first at your LDL, which gives a better clue than does your total cholesterol.
Optimal: Less than 100
Near Optimal: 100–129
Borderline High Risk: 130–159
High Risk: 160–189
Very High Risk: 190-plus

HDL (High-density lipoprotein, the “good” cholesterol)—Here’s where you actually want big numbers. Higher levels of HDL help to protect against heart disease.
Desirable: 60-plus
Average: 40­–50 (Men); 50–60 (Women)
High Risk: Less than 40 (Men); Less than 50 (Women)

Triglycerides
—High triglycerides, a form of fat, are often found in those with high total cholesterol. A level of 150-plus puts you at risk of metabolic syndrome, linked to heart disease and diabetes.
Normal: Less than 150
Borderline High Risk: 150–199
High Risk: 200–499
Very High Risk: 500

In a nutshell: The numbers in isolation don’t mean a heck of a lot. That’s why you should get a complete “lipid panel”—including all four components—when you have your cholesterol checked. A fasting blood test is all that’s needed. If you haven’t had one lately, ask your doctor. It could save your life—or give you peace of mind.

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