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Number 085
February 8, 2010
Robert Fusco, MD Robert Fusco, MD
Welcome to another e-newsletter from the Center for Digestive Health & Nutrition. Our physicians, nurse practitioner, and registered dietician provide this information to help improve awareness in matters of health and nutrition. Each issue - which now goes out to over 13,000 readers - focuses on a particular topic that we feel will be of interest. I want to thank our readers for their positive feedback and suggestions for future topics.

Lately, many of us baby boomers and older individuals are getting bad news from our doctors about our cholesterol level. Scientific studies have shown that the more aggressively we reduce our cholesterol, the lower our risk of heart attack and stroke. National guidelines have become much stricter and millions of Americans are being read the riot act by their doctor: start exercising, watch your diet, or plan to be put on cholesterol-lowering prescription medications. This may have caused some confusion - so for everything you always wanted to know about cholesterol, but were afraid to ask, read on...
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The Cholesterol Limbo:
How Low Should You Go?

by Robert Fusco, MD

Too Much of A Good Thing
Cholesterol is a fatty substance that is found in every cell in your body. Fats in the blood are called lipids. Cholesterol is a lipid. All the fats you eat are changed into a type of cholesterol or another group of lipids called triglycerides. Naturally produced by your liver, cholesterol is needed for normal body function. It helps carry fat to parts of your body that need it for energy and repairs. But, you can have too much of a good thing. Of all the threats to a healthy heart, too much cholesterol is the best known. Also called hypercholesterolemia, this condition markedly increases the risk of heart disease and stroke. As our population ages and becomes increasingly overweight, the problem worsens. Over 40 million Americans have high cholesterol and most don't even know it.

Good and Bad Cholesterol
Did you know that there are two kinds of cholesterol - good and bad? At first, doctors looked at total cholesterol numbers but then discovered that not all cholesterol was dangerous. Now when doctors talk about cholesterol, they are usually referring to "bad cholesterol" - also known as low-density lipoprotein, or LDL. LDL particles act like big boats, transporting cholesterol from the liver and depositing it in blood vessels, where it can build up on the inside of your arteries. plaque Like rusted pipes in an old basement, the arteries eventually become clogged and the flow of blood is reduced.

But, there is also so-called "good cholesterol" - also known as high density lipoprotein, or HDL. HDL is like Drano. Rather than clogging up your arteries, HDL cleans them by drawing cholesterol out of the artery wall and shuttling it back to the liver for excretion.

So, in your body, there is a continuous balancing act between the good and the bad. Not everybody's cholesterol reacts the same, but in general, having too much bad cholesterol (LDL) and not enough good (HDL) can increase your risk of heart disease and stroke.

Assessing Your Risk Level
If you are concerned about your personal risk of heart disease and stroke, there are four questions that you should ask your doctor:

  • What are your general risk factors for heart disease and stroke?
  • What are your current LDL and HDL levels?
  • How low should your personal LDL be?
  • How can you get it there?

General Risk Factors
Cholesterol isn't the whole story. There are many factors that your doctor must consider when assessing your overall risk of heart disease and stroke. The good news is that you don't need expensive or invasive testing to assess your risk. A simple office history and physical exam and a few blood tests can go a long way in predicting your personal risk.

To assess your personal risk, take this simple quiz.
Check off each item that applies to you:

Risk Factor Quiz

1.  Age over 45 (men) and over 55 (women)
2.  Cigarette smoking
3.  High blood pressure, over 140/80.
4.  HDL less than 40 mg/dl
5.  Close relative with heart disease - before 55 for a male relative and before 65 for a female relative
6.  Diabetes
7.  Obesity defined as a Body Mass Index over 30. You can calculate your BMI here .)
8.  Waist size over 40" (men) and over 35" (women)
9.  Preexisting heart disease or stroke
10.  Sedentary life style

For every item selected above, add 1 point. If your HDL is greater than 60, subtract one point. Two points give a person a 20% chance of a heart attack or stroke in the next 10 years. The more points you have, the greater your risk.

Ask Your Doctor For A Lipid Profile
All adults should have a periodic Lipid Profile to determine the level of LDL and HDL in their blood. At what age and how often you have your cholesterol level checked depends on your family history and other risk factors you have for heart disease. The blood tests are simple and require no preparation except for a 12 hour fast. Water is permissible. There is very little risk associated with taking blood from a vein in the arm, although occasionally, a bruise may develop in the area where the needle was inserted. Ask your doctor for the results, which are usually available in 2 - 3 days. Results are usually given in "mg/dL" which stands for milligrams per deciliter and is the standard unit of clinical measurement used to determine how much cholesterol, HDL cholesterol, LDL cholesterol, and triglycerides are in the blood.

Blood tests are best arranged by your personal physician who can assess other risk factors and make decisions about treatment if necessary. For those who are reluctant to visit their doctor, the FDA has approved two cholesterol test kits that can be purchased without a prescription. The First Check Home Cholesterol Test is a home test that only takes about 12 minutes, but measures only your total cholesterol level.

LDL: How Low Should You Go?
The point is that it depends upon your overall risk. The definition of a "normal" LDL must be taken in the context of the risk assessment above. Cholesterol levels are measured in milligrams (mg) of cholesterol per deciliter (dl) of blood. We are born with an LDL around 40 mg/dl, which rises with age. In general, the average middle aged adult should maintain an LDL below 130 mg/dl. For all diabetics and anyone with two or more of the risk factors above, current recommendations are to reduce the LDL to below 100 mg/dl. If you already have heart disease, the new guidelines are even stricter.


Number of Risk Factors
Target LDL mg/dl
Having 1 or no risk factors for heart disease Less than 160
Two or more risk factors for heart disease Less than 130
All Diabetics. Anyone with Existing Heart Disease (heart attack, angina, angioplasty, bypass) and one or more risk factors Less than 100
Existing Heart Disease and two or more risk factors Less than 70

When it comes to LDL in patients at the highest risk of heart disease, lower is better. A national panel of experts - including the American Heart Association, the American College of Cardiology, and the National Institutes of Health - released a revised set of guidelines in July 2004. The latest information is clear: based on the latest scientific studies, LDL should be no higher than 70 mg/dl in patients with established heart disease and more than 2 risk factors. This recommendation replaces the previous target of 100 mg/dl. The new recommendations are likely to sharply increase the use of statin drugs. Under these guidelines, over 20 million Americans are currently being under treated and it's almost impossible to reach such low LDL levels without cholesterol-cutting medications.

How do you lower your LDL?
For most individuals with modest elevations of LDL and few risk factors, simple measures may suffice.

    Get more exercise. Start slow and gradually work up to about 30 minutes daily. Fewer than 15% of Americans get adequate amounts of exercise, but exercising regularly is one of the best ways to reduce the risk of heart disease. A 3-tiered exercise plan which rotates low-impact cardiovascular exercise, strength training, and stretching is best, but you don't have to join a gym. Even a simple 30 minute walk daily can improve your health. If you are over 50, you should always check with your doctor before starting a new exercise program.

    Maintain a normal body weight. The answer to our epidemic of heart disease cannot rest in the pharmaceutical industry alone. Americans are getting too fat. Nearly 119 million American adults - 65 percent of the population - are now overweight and many of those are carrying 100 pounds more than they should. Reducing body weight to normal levels can sometimes dramatically lower LDL. Normal weight is best assessed by calculating your Body Mass Index, or BMI.

    Click here to calculate your Body Mass Index (BMI)

    Eat less animal fat. Dietary changes are usually the doctor's first recommendation. Animal fat contains cholesterol and saturated fat which creates more LDL in the bloodstream. Eat less animal fat and substitute products with polyunsaturated fatty acids such as olive oil. One example is Olivio Premium Spread; an alternative to butter that is made from olive oil blended with canola oil, both healthful oils. Another cholesterol-lowering margarine is Benecol, a spreadable margarine product fortified with compounds called phytostanol esters made from pine tree pulp that block the absorption of dietary cholesterol, thereby lowering blood cholesterol levels.

    Fish, poultry without skin Sausage
    Lean beef Liver
    Skim or 1% milk Whole milk
    Sherbet, sorbet, ice milk Ice cream
    Egg whites Egg yolks
    Steamed vegetables Fried vegetables
    Baked potatoes French fries
    Clear soups Creamed soups
    Olive oil Butter
    Corn, canola, safflower oils Coconut oil, palm oil, lard, bacon fat
    Angel food cake Cheesecake
    Pretzels Pastries, cookies
    Whole Grain English muffins Donuts
    Fruits Potato chips

    Eat more soluble fiber. Simply, dietary fiber - also called roughage or bulk - is the part of plants that cannot be digested by the body. Dietary fiber is found in grains, fruits, and vegetables. There is no fiber in animal products such as meat, fish, eggs, or dairy products. Just as there are many types of plants, there are also many types of dietary fiber. Some fibers can be dissolved in water (soluble fiber) and inside the small intestine form a jelly-like bulk that can lower cholesterol and reduce blood sugar. A diet high in soluble fiber can reduce LDL by as much as 15%. Soluble fiber can be found in foods such as oat bran, apples, citrus, pears, peas, beans and psyllium.

A repeat lipid profile is usually performed several months after starting a new diet and exercise program. Unfortunately, even though you can lower your LDL by changing what you eat, studies have shown that the average person achieves only a modest reduction of about 4-13% by diet alone.

Statins: the mainstay of prescription drug therapy
When lifestyle changes in diet and exercise aren't sufficient, your doctor may prescribe medication to help lower your LDL cholesterol. The most common drugs used are known as statins. Statins work by blocking an enzyme in the liver that the body uses to produce LDL cholesterol. By blocking this enzyme, statins are very effective. They can lower LDL cholesterol levels up to 60 percent and greatly reduce the risk of heart attack and stroke. The first statin, Mevacor, came on the market in 1987. Now there are five others in the United States. About 36 million Americans take statins - roughly one-half of the number for whom they are recommended. Common statins are listed below:

    Brand Name Generic Name Dose in mg.
    Mevacor lovastatin 10, 20, 40
    Lipitor atorvastatin 10, 20, 40, 80
    Pravachol pravastatin 10, 20, 40, 80
    Zocor simvastatin 5, 10, 20, 40, 80
    Lescol fluvastatin 20, 40, 80
    Crestor rostvastatin 5, 10, 20, 40

    Statins are best taken once a day at dinnertime, since the body manufacturers most of its cholesterol at night. Grapefruit juice affects the metabolism of Zocor, Mevacor, and Lipitor, and should be avoided. Taking these cholesterol-lowering drugs at the same time as grapefruit juice can increase the risk of muscle toxicity. The problem occurs because grapefruit contains a chemical that inactivates a liver enzyme involved in drug metabolism. As a result, regular consumption of grapefruit juice can lead to excessively high levels of medicine in the blood. However, Pravachol, Lescol, and Crestor are metabolized differently and are not affected by the ingestion of grapefruit juice. They should not be taken during pregnancy.

    Side effects
    Like all drugs, side effects may occur. Statins have been known to cause liver and muscle problems. But recent studies involving thousands of patients found that side effects are relatively rare. Abnormal liver blood tests are found in less than 1% of patients taking any statin - usually in the first 12 weeks of therapy. They need not be repeated after 12 weeks unless the dose of statin is increased. A more important side effect of statin usage is muscle pain. About 2% of patients on statins will develop muscle pain or weakness. They must stop the drug immediately to prevent permanent muscle damage known as myopathy. If the drug is continued, muscle damage and secondary kidney damage can occur. On August 8, 2001, a statin made by Bayer called Baycol (cerivastatin) was withdrawn from the market because of increasing reports of rare, but severe and sometimes fatal muscle damage called rhabdomyolysis.

What if statins don't work?
Statin drugs have helped millions of Americans lower their cholesterol, but statins don't work as well for some as they do for others. If you are in a high risk group and you are not reaching your new LDL target, your doctor might try combining a statin with other medications.

One such drug is Niacin, also known as nicotinic acid or vitamin B3. Niacin lowers the total cholesterol, "bad" LDL-cholesterol, and triglyceride levels, while raising the "good" HDL-cholesterol level. It is inexpensive and widely accessible to patients without a prescription, but must not be used for cholesterol lowering without the monitoring of a physician because of the potential serious side effects. It is seldom used as a primary form of treatment.

Bile acid resins work by binding to the bile acids your liver makes for use in digestion. The resins remove much of the bile acid from inside your small intestinal tract. When your body works to replenish the supply of bile acid, it takes cholesterol--a major building block for bile acids--out of the bloodstream. The result: lower levels of cholesterol in the blood. Doctors sometimes prescribe bile acid resins in combination with other cholesterol-lowering drugs such as one of the statins to lower blood cholesterol levels even further. The common bile acid resins are Questran (cholestyramine), Colestid (colestipol) and WelChol (colesevelam).

Sometimes a combination of a low dose statin with a different medication called Tricor (fenofibrate) will work when a statin alone does not. With this treatment, liver blood tests must be followed closely. This combination can also help reduce another blood fat called Triglycerides and may raise the HDL level somewhat.

A few years ago, a new type of drug Zetia (ezetimibe) was approved by the FDA in the battle against high cholesterol. Unlike statins which block excessive liver production of cholesterol, Zetia works in the small intestine by blocking absorption of cholesterol from the diet. In fact, Zetia is also offered in combination with the statin Zocor and sold as Vytorin. This drug was widely advertised and very profitable for Merk pharmaceuticals. Unfortunately, more recent studies suggest that while Zetia may decrease LDL cholesterol somewhat, it does not prevent clogging of the arteries. There also have been cases of liver damage from the use of Zetia so it has lost much of its original appeal.

Policosanol (poly-CO-sanol) is a non-prescription dietary supplement that some say may help reduce LDLcholesterol. Originally found in Cuba, policosanol is a natural plant product derived from sugar cane. Policosanol acts on cholesterol metabolism in the liver, but at a different part of the metabolic pathway than statins. Unfortunately, when studied scientifically, there was little benefit. In another independent study on Cuban policosanol in 2006, German researchers found it ineffective. Another study found policosanol made in the U.S. from sugar had no effect either. It’s also not known if other sources of policosanol, besides sugar, work. In European studies, neither policosanol from wheat germ nor policosanol from rice showed benefits. and it can't be recommended. Policosanol also reduces the "stickiness" of platelets, the blood elements that promote blood clotting, so this supplement should be used with caution, if at all, in patients taking blood thinners such as Coumadin. No other major drug interactions are known.

LDL Apheresis
Most patients with high cholesterol levels can be treated using a combination of diet, exercise and drugs. Some patients who have dangerously high cholesterol due to a rare hereditary condition, however, do not respond to strong drug treatments. Until recently, these patients had no treatment option. Now a new procedure called LDL apheresis is an option. Similar to kidney dialysis, blood is removed from the body, chemically cleansed of LDL cholesterol, and then returned to the body. This treatment takes several hours, is very costly, and must be repeated every two to three weeks, however it can reduce LDL cholesterol levels by 50 to 80 percent.

HDL: How High Should You Go?
Since HDL helps prevent heart disease, the higher the better. Having plenty of HDL - at least 60 mg/dl - can lower your risk of heart disease, and a low HDL - less than 40 mg/dl - can raise your risk of heart disease. Even small increases in the HDL cholesterol level can significantly reduce your risk. An increase in HDL cholesterol by 1 mg/dl decreases the risk of heart attack by 2% in men and 3% in women

Unfortunately, although we now have a variety of effective therapies to lower LDL, there currently is a no simple way to raise your HDL. Current therapy includes exercise (especially lower body workouts with weights that build the quads such as squats, leg extensions, and leg presses), a diet high in monounsaturated fats (olive oil, peanuts, hazelnuts, almonds, macadamia nuts) and foods rich in omega-3 fatty acids (walnuts, soybeans, flaxseed, mackerel, lake trout, herring, sardines, albacore tuna and salmon).

Alcohol in moderation ( men = 2 drinks per day; women = 1 drink per day) also raises the HDL somewhat. A few studies suggest that red wine and beer, which contain flavonoids, have the most beneficial effect. A drink is defined as 12 oz of beer, 5 oz of wine, or 1.5 oz shot of 80-proof spirits. Drink more than that and you can do more harm than good by weakening the heart muscle. Flavonoids are also found in purple grape juice.

Stopping smoking is mandatory! Smoking decreases HDL. Cigarette smoking increases the risk of coronary heart disease by itself. When it acts with other factors, it greatly increases the risk. Smoking increases blood pressure, decreases exercise tolerance and increases the tendency for blood to clot. Cigarette smoking is so widespread and significant as a risk factor, that the Surgeon General has called it "the most important of the known modifiable risk factors for coronary heart disease in the United States."

Convincing Patients
Prevention is always a hard sell. Many people who should be on drug therapy are not. Like many serious ailments, there are no symptoms for heart disease or stroke until the damage is done. It is difficult and time consuming for a doctor to convince a high risk patient who feels fine and has no apparent symptoms, to commit to a lifetime of expensive drug therapy. Even when prescriptions are written, many patients simply stop taking them. Conventional wisdom among doctors is that for drugs in general, the dropout rate by the end of the first year is 40 to 50 percent. Fortunately, public health efforts in patient education are working. More and more "baby boomers" are becoming health conscious and accept the concept of "preventative maintenance" for their bodies, just as they do for their cars.

The bottom line on cholesterol is that it is far easier to prevent trouble before it starts than to repair damage once is has occurred. You should know your current LDL "bad" cholesterol number. It gives you and your doctor a standard for good health much like your temperature, pulse, or blood pressure. Yet, according to a recent Gallop Poll, 61% of Americans do not know their cholesterol screening levels. Your LDL target is based on your current medical history, HDL level, and any other risk factors you may have for heart disease. The average person should try to maintain an LDL level below 130 mg/dl. If you have heart disease or diabetes, your goal is less than 100 mg/dl. Recent studies have shown significant benefit to reducing LDL to around 70 mg/dl in those individuals of highest risk or established heart disease. If you don't know what your individual LDL goal should be, ask your doctor.

For more information, go to the Live Healthier, Live Longer website which is sponsored by the National Cholesterol Education Project and the National Institutes of Health.

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