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Lately, many of us baby boomers and older individuals are getting bad news from our doctors about our cholesterol level. Five recent scientific studies have all 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...

Too Much of A Good Thing
Cholesterol, a fatty substance naturally produced by your liver, 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. 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?
  

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

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.

Blood tests are best arranged by your personal physician who can best 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 CholesTrak® Cholesterol Test is a home test that only takes about 10 minutes, but measures only your total cholesterol level. A more useful product is the BioSafe Cholesterol Panel. After a 12 hour fast, a simple finger prick is self-collected at home and a few drops of blood are sent to a certified laboratory which performs a full lipid panel including the Total Cholesterol level plus HDL, LDL & Triglycerides. The cost is about $35 and shipping is free. An easy to understand report is mailed back a short time later.

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 undertreated 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.

EAT MORE	EAT LESS
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
Bagels, 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 13 million Americans take statins - roughly one-third 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.

Recently, a new 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 a 2-week clinical study in 18 hypercholesterolemic patients, Zetia inhibited intestinal cholesterol absorption by 54%. Zetia is mst effective when combined with a statin. In fact, Zetia is also offered in combination with the statin Zocor and sold as Vytorin.

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 is associated with a 2% to 4% reduction in the risk of heart attack.

Unfortunately, although we now have a variety of effective therapies to lower LDL, there currently is a paucity of drug therapies to raise the 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, flaxsee, mackerel, lake trout, herring, sardines, albacore tuna and salmon). There is a slight rise in HDL when current prescription medications are used, but the effect is not great.

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."

Policosanol (poly-CO-sanol) is a non-prescription dietary supplement that may help some patients reduce their LDL and raise their HDL cholesterol by as much as 10 - 25%. 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. The usual dose is 20 mg a day. Policosanol 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.

Two exciting new therapies are on the horizon which may address a low HDL problem. Preliminary studies released in April 2004 noted a dramatic 60 - 106% increase in HDL levels when a new compound called torcetrapib was taken 1 to 2 times daily. This is an exciting breakthrough that should be generally available in several years.

Even more intriguing is the story of Limone sul Garda, a small town in Northern Italy. Thirty years ago, researchers found 40 villagers who seemed immune to heart disease despite unhealthy cholesterol levels. After years of careful study, it was discovered that these individuals were born with a protein mutation which made their HDL even more powerful - like "super Drano."

It was named ApoA-I Milano after the city of Milan, where the initial laboratory work was done. In effect, these villagers had self-cleaning arteries. Recently, medical scientists at the Cleveland Clinic have been able to create a synthetic form of this protein currently called ETC-216. Preliminary human studies have shown that IV infusions of ETC-216 can actually begin to reverse heart disease in a few weeks time. Expect to hear more about this drug in years to come.

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.

Summary
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.