Cholesterol, Part Two: A Patient Guide

If your cholesterol is too high, it's time to take action. Lowering your total cholesterol levels can reduce your chance of suffering a heart attack or stroke, or dying of heart disease. If you already had a heart attack, keeping your cholesterol under control is especially important to avoid another.

A word about “epidemic obesity” affecting Westernized societies

Everyone is hearing about the “obesity epidemic”. This can be blamed on our successful battle against hunger. Everyone now has access to the foods that their grandparents didn’t. We get fruit and vegetables in the winter, and meat doesn’t need to be hung outdoors. Refrigerators measure more than 8 cu feet, and freezers actually freeze things. Icemen don’t really deliver large cubes of ice to residences anymore. But now metabolic syndrome is estimated to affect approximately 25 percent of all adults in America. Metabolic syndrome is identified by the presence of 3 or more of the following:

• Abdominal obesity, meaning a waist circumference greater than 40 inches in men or greater than 35 inches  in women
• A triglyceride level greater than 150 mg/dL    
• An HDL level lower than 40 mg/dL in men or lower than 50 mg/dL in premenopausal women
• Blood pressure higher than 130/85 millimeters of mercury (mm Hg)
• A fasting blood sugar level between 100 and 125 mg/dL

Metabolic syndrome, like type 2 diabetes mellitus which it leads to, is a risk factor for arteriosclerosis.

Managing diet and weight, and increasing physical activity can help bring low-density lipoprotein (LDL) cholesterol down to normal levels. In view of the absolute benefits of lowering the cholesterol in the population, the federal government in the form of the National Heart, Lung, and Blood Institute (NHLBI) has supported a National Cholesterol Education Program (NCEP) in establishing guidelines for diet and exercise by experts in every health field.

Diet. Saturated fat and cholesterol in the food you eat contributes to your total blood cholesterol level. Saturated fat in all forms, and trans fats are the main culprit. Reducing the amount of saturated fat and cholesterol in your diet helps to lower your blood cholesterol level. The diet recommended by the NHLBI’s National Cholesterol Education Program (NCEP) is a low-saturated-fat, low-cholesterol eating plan that calls for less than 7 percent of calories from saturated fat and less than 200 milligrams of dietary cholesterol per day. Trans fats are also to be avoided.

Foods low in saturated fat include fat-free or 1 percent dairy products, lean meats, fish, skinless poultry, whole grain foods, and fruits and vegetables. Foods that are high in cholesterol, and thus should be limited, include liver and other organ meats, egg yolks, and full-fat dairy products. The NCEP diet recommends only enough calories to maintain a desirable weight and avoid weight gain. This is particularly important.

The NCEP recommends other therapeutic lifestyle changes as well. These include:

• Eating 10-25 grams of dietary fiber per day, especially soluble fiber. Plant-based foods that are high in soluble fiber – certain fruits and vegetables such as oranges, pears, brussels sprouts and carrots, as well as oats, dried peas and beans – do not contain dietary cholesterol, and also help your body excrete cholesterol before it is absorbed into the bloodstream.
• Eating 2 grams (about one tablespoon) per day of either plant stanols or sterols, which help prevent the absorption of cholesterol into the bloodstream. Sterols are found especially in vegetable oils, and in smaller amounts in fruits, vegetables, nuts, seeds, cereals, beans and other plant sources. Stanols can be found in some of the same sources, particularly vegetable oils. Some food products, such as Benecol Spread, have been fortified with stanols or sterols to help lower cholesterol.

Weight. Being overweight is a risk factor for heart disease. It also increases your cholesterol. Losing weight can help lower your "bad" cholesterol and total cholesterol levels. It is especially important for those with several risk factors, including high triglyceride (TG) and/or low high-density lipoprotein (HDL) cholesterol levels and being overweight with a large waist measurement (more than 40 inches for men and more than 35 inches for women). Weight reduction will also decrease blood pressure.

Physical activity. Not being physically active also is a risk factor for heart disease. Regular physical activity can help lower your "bad" cholesterol, raise your "good" cholesterol levels and help you lose weight. You should try to be physically active for 30 minutes on most, if not all, days. This is especially important if you have high triglyceride and/or low HDL cholesterol levels, and are overweight with a large waist measurement. Regular physical activity will also result in a lower blood pressure.

There also are a number of factors that can affect your cholesterol levels that you cannot control. As men and women get older, their cholesterol levels rise. Elevated LDL cholesterol levels are a particular concern for postmenopausal women. Before menopause, women have lower total cholesterol levels than men of the same age. However, after menopause, women’s LDL levels rise.

There are many reasons for high cholesterol that are due to genetics. Your parents determine how much cholesterol your body makes through the genes they gave you. High cholesterol does run in families. To reduce your risk for heart disease, it is very important to control any other risk factors you may have, such as high blood pressure, smoking (it lowers your HDL), and diabetes. Diabetes (whether early onset type 1 or later onset type 2) poses as great a risk for having a heart attack as heart disease itself. The NCEP guidelines recommend that high cholesterol be treated more aggressively for those with diabetes. Besides their very high short-term risk for having a coronary event, people with type II diabetes also have a particularly high risk of dying from a heart attack. Type II diabetes is the most common form of the disease and affects more than 20 million Americans.

Lowering cholesterol with medication

Drug treatment is used in conjunction with dietary changes to lower cholesterol levels. This will keep the dose of medicine as low as possible, and lower your risk in other ways as well. Several types of drugs are available for cholesterol lowering, including statins, bile acid sequestrants, niacin, and fibric acids. Based on the different types of medications available, your doctor can help decide which one is best for you.

Statins. Proven to be highly effective and well tolerated in most patients, statins are regarded as the treatment of choice for lowering "bad" cholesterol levels. There are many such drugs, and some are sold as combinations with other drugs to either lower LDL cholesterol raise HDL cholesterol or lower blood pressure as well. Statins have a remarkable record for the reduction of cholesterol and prolongation of survival in patients with vascular disease. This is called secondary prevention (because vascular disease has already been present). Primary prevention trials (people who have not yet had a cardiovascular event) also appear positive and the medicines are quite well tolerated by most people. While the frequency of side effects with these medications is generally very low, nausea, gas, constipation, and abdominal cramping may occur. Headache, muscle pain, and liver problems have been reported in some cases. Currently available statins include atorvastatin (Lipitor), fluvastatin (Lescol), lovastatin (Mevacor), pravastatin (Pravachol), rosuvastatin (Crestor) and simvastatin (Zocor).

The voluntary withdrawal of cerivastatin (Baycol), a statin linked to about 100 deaths worldwide from a severe muscle deterioration condition called rhabdomyolysis, had raised concerns about the safety of statins. However, the largest study of statins, released in November by investigators in the United Kingdom, concluded that statins are safe and can benefit men and women, people of all ages, diabetics, and even those with normal cholesterol levels. The FDA however after long discussion has felt that they should not be available over the counter without a doctor’s prescription as cholesterol levels and liver function tests need to be checked on a regular basis.

Bile acid sequestrants. These drugs also lower LDL levels and can be used alone or in combination with statin drugs. This type of drug includes cholestyramine (Questran), colestipol (Colestid), and colesevelam (Welchol). Bile acid sequestrants keep the body from the body from absorbing or reabsorbing cholesterol and can be unpalatable and cause intolerable gastrointestinal effects (such as bloating, gas, abdominal pain, and constipation) at the level of dosage required to lower LDL cholesterol levels. Because of these potential side effects, these drugs are mostly used in combination with statins when further lowering of total cholesterol or LDL cholesterol is needed. They also can be used alone for patients who cannot take statins. A newer drug, ezetemibe has been very popular and has also been combined with simvastatin to lower cholesterol in the hope that it would further lower the risk of cardiovascular events. To this point the combination appears disappointing in clinical studies (Vytorin).

Niacin (nicotinic acid). Niacin, a B vitamin, lowers LDL and triglyceride levels, and raises HDL cholesterol levels. It is the most effective drug available for raising HDL cholesterol levels. Side effects include hot flashes, nausea, indigestion, gas, and high blood sugar. As with statins, some combination pills have also been approved with other medications. High doses of niacin can also cause liver abnormalities. Multiple preparations promise lesser side effects but not all deliver.

Fibric acids. These medications lower LDL a bit but are used mainly to treat high triglyceride and low HDL levels. The most well studied of these agents is gemfibrozil (Lopid).  Fenofibrate (Tricor), and other preparations are members of this class. Fibrates are generally well tolerated but can occasionally cause some side effects such as nausea, bloating, gas, and the formation of gallstones. Since these drugs are only somewhat effective in lowering "bad" cholesterol levels, fibrates are often used in conjunction with another drug, such as statins, to reduce LDL levels. These drugs can also cause some muscle discomfort.

Word of caution on estrogens

Estrogen helps to decrease LDL cholesterol levels in postmenopausal women. For a long time, experts in the field of women’s health and heart disease considered estrogen replacement therapy (or hormone replacement therapy) an effective way to reduce a postmenopausal woman’s risk of developing future heart disease. A number of large, well-designed studies have demonstrated however that estrogen replacement does not help lower future risk of heart disease. For some women, especially those that are older, hormone replacement therapy may even increase the risk for developing future manifestations of heart disease. In view of these findings, estrogen or combinations of estrogen and progesterone are no longer recommended to reduce risk in menopausal, or post-menopausal women. In those women undergoing the vasomotor side effects of the change should discuss the treatment with their health care provider.  Fortunately, the other medications (e.g. statins) currently available for lowering LDL cholesterol levels appear as equally effective for women as men.

Next steps

Once your "bad" (LDL) cholesterol goal has been reached, your doctor may prescribe treatment to lower your triglycerides, increase your level of "good" (HDL) cholesterol, or both. The treatment includes losing weight if needed, increasing physical activity, quitting smoking, and possibly taking a prescribed medication.

Sources

National Heart, Lung, and Blood Institute. National Cholesterol Education Program. High blood cholesterol. What You Need to Know. Accessed January 17, 2002.

National Heart, Lung, and Blood Institute. Coronary heart disease explained. Accessed January 17, 2002.

What you should know about cholesterol. The Aging Female Patient. June 2001, Volume 26 (supplement), pages 49-50.

National Institutes of Health. NCEP Issues Major New Cholesterol Guidelines [press release]. Accessed January 17, 2002.

National Heart, Lung, and Blood Institute. National Cholesterol Education Program. ATP III guidelines at-a-glance. Quick desk reference. Accessed January 17, 2002.

James McKenney; New guidelines for managing hypercholesterolemia. Journal of the American Pharmaceutical Association. July/August 2001, Volume 41, No. 4, pages 596-607.

Joel B. Braunstein, MD, et al; Lipid disorders. Justification of methods and goals of treatment. Chest. September 2001, Volume 120, No. 3, pages 979-988.

Qureshi AI, Suri MF, Guterman LR, Hopkins LN. Ineffective secondary prevention in survivors of cardiovascular events in the US population: Report from the Third National Health and Nutrition Examination Survey. Archives of Internal Medicine. July 9, 2001; Volume 161, No. 13, pages 1621-1628.