Cholesterol: How Low Should You Go?

[Guest guest]

Hi All,

This month's Wellness Letter is in. Go to

http://www.WellnessLetter.com = Berkeley Wellness Letter.

I most enjoyed using the password, " hopeful " , to acess:

http://www.wellnessletter.com/subCorner/RA2004/scRA0704_01.php,

which stated:

" New Advice for a Healthy Heart

For: Cholesterol: How Low Should You Go?, July 2004

We reported in February on the growing popularity of cholesterol-

lowering " statin " drugs, which many healthy people take to prevent

heart disease. Among the most widely prescribed drugs in the world,

statins will surely be even more popular now that an important

government-sponsored panel of heart disease experts has announced

aggressive new recommendations for treating high blood cholesterol.

If everyone followed the guidelines, it's estimated that 65 million

Americans would change their diet and make other life-style changes,

up from 50 million under the old guidelines, and as many as 36

million would take cholesterol-lowering drugs, compared to the

current 13 million. Recent studies show that such preventive

treatment could substantially cut the number of deaths from heart

disease, the No.1 killer in this country.

Under the new guidelines, many more Americans are considered to be at

high risk for a heart attack than before, and are thus candidates for

cholesterol-lowering life-style changes and possibly drug therapy.

Now more than ever, you really need to work with your doctor to

evaluate your level of risk. Even if you have previously had your

blood cholesterol measured and discussed your heart health with your

doctor, the new guidelines mean that you'll need re-evaluation.

Here are some of the main changes in testing and treatment that may

affect you:

• First, everyone age 20 or older should have a complete blood

cholesterol test, called a " lipid panel " or " lipoprotein profile, "

which, unlike the simpler screening test, requires a 12-hour fast.

This measures total cholesterol, as well as LDL ( " bad " ) and HDL

( " good " ) cholesterol and triglycerides (fats in the blood). You also

need to know your blood pressure.

• While the guidelines for total cholesterol haven't changed (below

200 is " desirable, " 240 and above is " high " ), those for LDL and HDL

have. Desirable LDL levels (now called " optimal " or " near optimal " )

are still less than 130, unless you're at high risk for a heart

attack (see below), in which case the new goal is a very low 100. In

the past only those who already had heart disease needed to aim for

this stringent target. For most people, this requires medication. The

minimum for HDL has been raised to 40, up from 35. HDL below 40 is

considered a coronary risk factor.

• The risk factors for heart disease are mostly the same, notably

age, smoking, high total and/or LDL cholesterol, low HDL, high blood

pressure, family history of premature heart disease, and obesity.

These factors are even more important now in determining how

aggressively your elevated cholesterol will be treated.

• Diabetes is now singled out as so potent a risk factor for heart

disease that by itself it puts you in the highest-risk category,

along with people who already have heart disease. So everyone aged 45

and over should be tested for diabetes. And people with diabetes now

need to get their LDL below 100, which usually requires drug therapy.

• One new risk factor is called " metabolic syndrome, " which is

largely related to obesity and inactivity. You qualify if you have

three or more of the following: abdominal obesity (a waist more than

40 inches for a man, 35 for a woman); low HDL (below 40 for a man, 50

for a woman); fasting triglycerides of 150 or more; elevated blood

pressure; and fasting glucose of 110 or more.

The risk calculator

The guidelines include a " risk calculator, " based on research from

the famous Framingham Heart Study. It uses your age, cholesterol

levels, smoking status, and blood pressure to come up with your risk

for having a heart attack during the next decade. The calculator does

not, by itself, provide the whole picture, however, and the results

can be confusing. You should do this risk assessment test with your

doctor. The results, along with your LDL level and other risk

factors, will help your doctor determine how much you need to lower

your LDL through life-style changes and perhaps cholesterol-lowering

drugs.

Still, if you want to try this formula yourself, it's easiest to use

the government's website, which also provides lots of helpful

information about coronary artery disease. You can also get a free

copy by writing to the NHLBI Information Center, P.O. Box 30105,

Bethesda MD 20824-0105, or call 301-592-8573; ask for " High Blood

Cholesterol—What You Need to Know. "

Living the good life

The guidelines also stress the importance of life-style changes, even

for those taking medication. These steps include exercising, losing

weight (via calorie reduction), stopping smoking, and especially

adopting a cholesterol-lowering diet. For people with elevated blood

cholesterol and risk factors, the dietary goals are stringent: lower

saturated fat (less than 7% of total calories, instead of 10% on the

usual heart-healthy diet) and lower dietary cholesterol (less than

200 milligrams a day, down from 300). But they do allow for more

monounsaturated fat (up to 20% of total calories, instead of 10 to

15%, especially for those with diabetes or the " metabolic syndrome "

described above). There's also new emphasis on consuming lots of

cholesterol-lowering soluble fiber, like that found in oats and

beans, along with plant compounds called stanols or sterols, found in

some specialty margarines, such as Benecol.

Most people, and many doctors, are going to focus on the drug advice

in the new guidelines, rather than the life-style advice. That would

be a mistake. Statin drugs are expensive—$1,000 to $1,800 a year—and

presumably you'll have to take medication for life. While they seem

to be safe and work well (and may have other benefits, too), statins

can cause minor side effects, such as gastrointestinal upset, sleep

problems, and rashes. More rarely, statins can cause severe muscle

and liver damage, so you need periodic blood tests for liver

function. In addition, no one knows how safe they are when taken for

many years or decades.

Last words

The new recommendations make it all the more important that you talk

to your doctor about heart disease. They also make it more likely

that doctors will quickly put more patients on statins (or other

cholesterol-lowering drugs). That will save lives, but having tens of

millions of Americans on cholesterol-lowering drugs is a far-from-

perfect solution. Most people don't give life-style changes a real

chance, and their doctors don't help them enough in their efforts.

Take medication if you need it, but make sure you really need it

first. Losing weight, becoming more active, improving your diet

(especially by eating more fruits, vegetables, and whole grains), and

stopping smoking will help keep you healthy in many ways besides

lowering your cholesterol. These steps, for instance, will also help

prevent diabetes and " metabolic syndrome, " two of the big risk

factors for heart disease. "

The optimum total cholesterol level in the blood is 100 mg/dl (2.6

mM)? The WUSTL study CRers had levels of 158 versus the controls'

205 mg/dl. Mine was just above 100.

Al Pater.