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Cholesterol and Your Health
By Debra Gordon

How new understanding can help you see past the myths and take the steps to stay healthy.

You’ve seen the ads. “Looks can be deceiving,” the tag line reads. Then it shows an overweight middle-aged guy standing next to a slim young woman. Guess who has the higher cholesterol levels? If you guess the man, you’re wrong. And that’s the purpose of the ad: to destroy the myth that you have to be old and overweight to have high cholesterol levels.






Cholesterol By the Numbers
If you know your cholesterol levels, check this chart to get a better understanding what the numbers mean.


The Medication Maze
Tired of paying upward of $100 or more a month for your statin drugs? Get the latest info on generic statins.
There are numerous myths about cholesterol, the soft, faintly yellow, naturally occurring waxy substance found everywhere in your body. One of the worst is the myth that the word “cholesterol” is synonymous with “bad.” Dubbing all cholesterol “bad,” however, is like calling all teenagers juvenile delinquents.


Cholesterol is actually quite a handy substance, used to produce sex hormones, vitamin D and bile acids that help you digest fat. As with everything, however, too much of even a good thing is not quite so good. (See “Cholesterol By the Numbers.”)


Cholesterol Deconstructed




Exactly what do we mean when we talk about cholesterol? First of all, it’s not the cholesterol per se you should worry about, but the type of protein carrying it around. You’re probably most familiar with the two main types:


• LDL (low-density lipoprotein) and


• HDL (high-density lipoprotein).


LDLs carry most of the cholesterol in your blood. They’re considered the “bad” guys because they deposit extra cholesterol throughout your body, including in your arteries. Once there, these particles burrow into artery walls, beginning a cascade of events that eventually results in plaque buildup in artery walls, narrowed blood vessels and, possibly, a heart attack or stroke.


For years, researchers have focused on reducing LDL levels, helped, in part, by the blockbuster class of drugs known as statins. Since the drugs came into use in the 1990s, numerous studies have shown that not only do they lower LDL levels, they also reduce the incidence of cardiac events, such as heart attacks and angina. The question is: How low should we go?


One large trial recently published in the New England Journal of Medicine followed more than 4,000 patients with high LDL cholesterol levels who had been hospitalized for either heart attacks or unstable angina. In the study, called “Prove It,” volunteers took one statin designed to bring their LDL levels to 100 mg/dl (milligrams per deciliter), then considered the target level, or another designed to bring their LDL cholesterol levels to the substantially lower target level of 70 mg/dl.


While both groups’ cholesterol levels improved significantly on the drugs, those who got their LDL levels down to 70 mg/dl or below reduced their risk of heart attack or other major cardiac events 16 percent more than those who only got to the recommended target of 100 mg/dl.




That study, along with others, prompted the National Heart, Lung and Blood Institute, the American Heart Association, and the American College of Cardiology in July to recommend new target levels of LDL for people at high risk of heart disease. You’re considered “high risk” if you smoke, are overweight, have diabetes or high blood pressure, or have a history of heart disease, among other factors.


But LDL only tells half the cholesterol story. For the other half, you have to think about your HDL levels.


HDL: The New “Good Guy”


HDL is the “good guy” of the cholesterol system. It acts like a garbage truck, scooping up extraneous cholesterol as it moves throughout your body and depositing it in your liver for later elimination. When it comes to HDL, you want to get your levels as high as possible.


Why? Well, consider this: Every 1 percent increase in your HDL level reduces your risk of a heart attack 3 to 4 percent, while a 1 percent drop in your LDL level reduces your risk of a heart attack just 2 percent.


The amazing results from studies like “Prove It” rely, to some degree, on HDL levels. When Richard Karas, M.D., director of Preventive Cardiology at the Women’s Heart Center at the New England Medical Center in Boston, and his colleagues reanalyzed data from such studies, they found that the ultra-low LDL levels only provided extra benefits in patients who also had high HDL levels.


“So it still matters whether HDL is low or high, even when you drive the LDL to these ultra-low levels,” says Dr. Karas.




The American Heart Association recognized that in February, when it raised the recommended level of HDL for women by 25 percent from 40 mg/dl to above 50 mg/dl. Unfortunately, an estimated 28 million women now have HDL levels too low. Overall, the American Heart Association estimates that more than 53 million U.S. adults – about one-quarter of the population – have low HDL levels. Low levels are especially common among people who get heart disease earlier than usual and is one of a cluster of risk factors that predispose people to diabetes.


Increasing HDL Levels


So we have the magic statins to bring down LDL levels. What about increasing HDL levels?


Today, two medications are approved to increase HDL levels. Both work just so-so. Nicotinic acid, a prescription strength form of the B vitamin niacin, can raise HDL levels as much as 26 percent. Fibrates, primarily used to lower triglycerides, can increase HDL levels up to 20 percent.


New hope is on the horizon, however. The most exciting new drug under development is Pfizer’s torcetrapib. Brought to you by the same people who brought you the blockbuster Lipitor, the most-prescribed drug in the world, torcetrapib belongs to an exciting new class of drugs called CETP inhibitors. These drugs reduce production of a protein called cholesterol ester transfer protein (CETP), which is responsible for transferring fats between lipoproteins. People with high levels of CETP generally have low levels of HDL.


A study published in the New England Journal of Medicine in April found that twice daily doses of torcetrapib increased HDL levels a whopping 106 percent in 19 women with low levels. The data, says Emma Meagher, M.D., the associate director of the cardiovascular risk intervention program at the University of Pennsylvania, which participated in the study, is very encouraging.


“You can appreciate that if we have the potential of significantly raising HDL cholesterol by whatever means, we can expect to potentially achieve a marked further reduction in cardiac events,” Dr. Meagher says. Translation: Higher HDL levels equals fewer heart attacks.


Putting the Numbers in Perspective




So what does it all mean?


Well, for one, that the total cholesterol number you’ve been focused on is worthless.


“The importance of the full lipid profile has been recognized,” says David Katz, M.D., an associate clinical professor of public health and medicine at the Yale University School of Medicine and author of the books The Way to Eat and Cut Your Cholesterol! “A high HDL can compensate for a high LDL; when LDL is low, a low HDL may be unimportant.”


You also need to worry about triglycerides, a blood fat similar to cholesterol. High levels of triglycerides can also lead to plaque buildup, Dr. Katz says. “So total cholesterol does not tell the whole story,” he says.


So you should just put your trust in your doctor’s hands, right? Wrong. “If you talk to primary care physicians, while they all agree that lowering LDL is critically important, when you look at their performance, it’s nowhere near acceptable,” says Dr. Karas. And when you look at their efforts to raise patients’ HDL, he says, the picture is “about 10 times worse.” That’s particularly true with women.


When Karas and his colleagues examined hundreds of women’s medical charts, they found that the more risk factors a woman had for heart disease, the less likely she was to have a cholesterol value written in her chart. Another study of women with diabetes who had been hospitalized with coronary artery disease found most didn’t meet national standards for LDL levels, less than 19 percent had protective levels of HDL, and only 46 percent were taking LDL-lowering drugs. Moreover, of that 46 percent on the medication, fewer than half reached optimal LDL levels, suggesting they needed to be on higher doses or different drugs.


So you need to be proactive when it comes to your cholesterol levels. Make sure you get tested at least once a year and ask for the breakdown of your levels. If the levels seem high, talk to your doctor about your options.




Don’t Rely on Drugs Alone


Those options shouldn’t stop – or even necessarily start – with drugs, however. “Various studies show drops of 25 percent or more in total cholesterol from making many simple changes in your diet,” says Katz. The formula isn’t difficult:


Cut waaayyy back on saturated fat. That’s the kind of fat found in animal protein, like full-fat dairy and meat. Instead, choose nonfat dairy products and load up on fish, beans, poultry and lean cuts of meat (try venison and buffalo for a change). Ideally, no more than 7 percent of your overall calories should come from saturated fat.


• Go waaaayyy up on the amount of fiber you get in your diet. Not only does fiber fill your stomach without adding calories (because it’s not digested), but soluble fiber found in foods such as fruits, oats, barley and peas forms a kind of gel in your intestines that reduces your body’s overall absorption of fat. And that, in turn, helps lower cholesterol levels. Aim to get at least 25 grams of fiber a day.


• Use a cholesterol-lowering spread. Just a couple of teaspoons a day of a sterol-based spread like Benecol or Take Control can reduce total and LDL cholesterol levels 9 to 20 percent. Combined with soluble fiber, the two can rival the cholesterol-lowering power of statins, Katz says.


Increasing your HDL is a bit more difficult, but it can be done. Start with a glass of wine. Numerous studies find moderate alcohol intake makes a big difference in HDL levels. For instance, one study found half a bottle of white wine drunk every day for six weeks increased HDL levels 7 mg/dl – a significant jump. That’s about two glasses of wine a day. Of course, if you’re a teetotaler, don’t start drinking just to boost your HDL!


Other changes you can make to increase your HDL:




• Switch over to olive oil. This monounsaturated fat, and others like it, not only increases HDL but lowers LDL.


• Walk 30 minutes a day, five days a week. Over time, such moderate, sustained exercise can increase HDL levels.


• Lose weight. You’ll see a jump in your HDL.


Bottom line, says Katz, is that “by the end of the day, half the deaths from heart disease in this country are accounted for by behaviors that can be modified.”


RESOURCES


American Heart Association


Food and Drug Administration – A helpful article on “Keeping Cholesterol Under Control.”


Medline Plus – This online service of the U.S. National Library of Medicine and the National Institutes of Health provides several good articles on cholesterol.


National Heart, Lung and Blood Institute – Provides information on the National Cholesterol Education Program.



More Resources:



Cholesterol By the Numbers
If you know your cholesterol levels,
check this chart to get a better understanding what the numbers mean.


The Medication Maze
Tired of paying upward of $100 or more a month for your statin drugs? Get the latest info on generic statins.



Debra Gordon, an award-winning health writer and editor, is a frequent contributor to Get Up & Go.


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