It’s a healthy thing to exercise control over your life—particularly when it involves preserving it. Among the easiest ways to do that is by keeping your cholesterol low. High cholesterol is one of the primary and most controllable causes of heart disease and stroke—two of the top causes of death in the United States. According to the Centers for Disease Control and Prevention, one in three deaths in the United States is from heart disease or stroke.
The Good & The Bad
By Pamela Perkins
Why Cholesterol Matters
Cholesterol matters because it is one of the major controllable factors for coronary heart disease; the higher your cholesterol level, the higher your risk. According to Dr. David Wendt, a cardiologist at the Chattanooga Heart Institute at Memorial Hospital, the majority of patients with serious heart issues have high cholesterol in addition to a vascular issue, diabetes or high blood pressure.
In recent years, researchers have grown optimistic that cholesterol awareness and efforts to prevent high cholesterol have been increasing among adults. Studies conducted in 2009 showed that more adults are being tested for and are reporting high cholesterol.
This increase suggests that more people today are making lifestyle changes or receiving medical care for high cholesterol. Subsequently, high cholesterol among adults has actually been declining. In fact, a report published by the Centers for Disease Control (CDC) in April showed that from 1999 through 2010, the overall level of high cholesterol among adults over 20 dropped from 18% to 13%.
“There is an increased awareness of preventing heart disease, and controlling cholesterol is a part of that plan for many people,” says Dr. Melanie Blake, medical director of Academic Internal Medicine of UT Erlanger Physicians Group. While medication plays an important role in lipid management, “many patients are willing to undergo treatment by changing their diet, managing their weight, and increasing their physical activity.”
When people talk about cholesterol, they are usually talking about a total blood cholesterol level that has risen too high. But cholesterol is actually not a bad thing in itself.
A waxy, fat-like substance found in cell walls and membranes throughout the body, cholesterol helps produce sex hormones (including estrogen, progesterone, and testosterone), convert sunshine to vitamin D, and produce bile acids to help you digest fats. It also insulates nerve fibers and builds and maintains cell membranes. Most of your body’s cholesterol (about 85%, or 1,000 milligrams daily) is endogenous, meaning it is produced in your liver. The other 15% comes from your diet—from animal foods including meat, eggs, and dairy products.
Because cholesterol is a lipid, it can’t dissolve in the blood, so it hitches a ride with certain proteins—forming a “lipoprotein”—to maneuver through the bloodstream. A person’s “total cholesterol” measures two different types of lipoproteins: high-density lipoproteins, or HDL cholesterol, and lowdensity lipoproteins, or LDL cholesterol.
High-density lipoproteins (HDL) are the good guys—these carry cholesterol away from the tissues to the liver for processing and disposal. This is why you may have heard people call HDL cholesterol “good cholesterol.” Low-density lipoproteins (LDL) are the primary offenders— these lipoproteins carry about 75% to 80% of the cholesterol through the body, depositing it in cells and arteries.
If LDL cholesterol levels are high, cholesterol deposited on the walls of the arteries can contribute to the formation of a hard plaque. This decreases blood flow and can lead to atherosclerosis, i.e. the hardening of arteries, and subsequently, heart disease. Thus, LDL is often called “bad cholesterol.”
Knowing Your Numbers: The Lipid Panel
Testing for high cholesterol is crucial, as it has no overt signs or symptoms. The National Cholesterol Education Program (NCEP) suggests healthy adults age 20 or older be tested every five years, starting during the early 20s. However, more frequent checks will be necessary if obesity, a high-fat diet, a sedentary lifestyle or diabetes are in play.
Children as young as age 2 can have high cholesterol, but not all children will need to be screened. The American Academy of Pediatrics recommends a cholesterol test only for children who have a family history of high cholesterol or premature coronary artery disease. Screening is also recommended for children who have risk factors for high cholesterol, such as obesity, high blood pressure or diabetes.
A doctor will use what’s called a lipid panel, or lipid profile, to measure your body’s total cholesterol, including your LDL and HDL cholesterol levels. The table from the American Heart Association shown below offers some general guidelines for interpreting your results. However, you should always discuss your results with your doctor.
When it comes to lowering cholesterol, many people think in terms of lowering LDL (the “bad” cholesterol). However, many doctors say a better way to think about it is improving your HDL/LDL ratio (raising HDL, lowering LDL, or both). It’s true—your risk for heart disease is high if you have a high total cholesterol and LDL. However, your risk for heart disease is even higher if you have a low HDL.
This being the case, some health officials prefer measuring cholesterol by using a ratio of total cholesterol to HDL. For the ratio, divide your total cholesterol by your HDL. A ratio of 5:1 is good. A ratio of 3.5:1 is optimal.
The Scoop on Statins and Other Cholesterol Meds
Though medical professionals usually prefer lifestyle tweaks such as increased exercise to lower a patient’s cholesterol, sometimes a medicinal push is also needed. Hailed “the drug of the century,” statins are the most frequently prescribed medications for cholesterol management. Statins work by blocking HMG-CoA reductase, an enzyme the liver needs to make cholesterol. Popular brand names include Altoprev, Crestor, Zocor, Pravachol and Lipitor. A study released by the National Center for Health Statistics last year shows that about 25% of Americans ages 45 and older take statins. That’s about 32 million people.
While a minority of patients may be able to take statins temporarily while making significant lifestyle changes, most individuals will need to consider them a lifelong commitment. “It depends on the individual,” Dr. Wendt explains. “Let’s say you come in. You’re 40. You have a tendency towards diabetes. You have sleep apnea and high blood pressure and cholesterol of 280. The first goal is to get your total cholesterol under control with medicines. The second goal would be to lose the weight, bring the blood pressure down and watch your diet and bring yourself back on track. If you do all of those things, you may be able to go off the medication. But by the time you have a heart attack, you most likely will be on a statin from then on out.”
Statins are usually well-tolerated, but like any other medication, they can have side effects. The most common are muscle and joint aches. Other side effects may include nausea, constipation and diarrhea. Your doctor should alert you of any potentially serious side effects.
Other treatment options for high cholesterol include bile-acid binding resins and cholesterol absorption inhibitors. Bile-acid-binding resins such as cholestyramine (brand names Prevalite, Questran), colesevelam (Welchol) and colestipol (Colestid), lower cholesterol indirectly by binding to bile acids. This prompts the liver to use more cholesterol to produce bile, so that there is less cholesterol in the blood. Cholesterol absorption inhibitors such as ezetimbe (brand name Zetia) work by curbing the small intestine’s absorption of dietary cholesterol. Frequently, ezetimbe is used with a statin to minimize both cholesterol absorption and cholesterol production.
Your Diet and Cholesterol
Medication or no medication, it is important for patients to remember that without certain lifestyle changes, they will still be at an increased risk for heart disease. “It’s hard to stop, and it’s particularly hard to stop here,” Dr. Wendt says of weight control in the South. “This is grandma’s love. Southern cuisine is the recipe for building up plaque and causing heart attacks and strokes. The Southeast region from Louisiana over is both the stroke belt and the heart disease belt.”
One of the most important things a person can do when it comes to high cholesterol is to cut back on saturated and trans fats. Saturated fats—which are found in butter, cheese, whole-milk products, and red meat—are known to raise LDL. Trans fats—found in potato chips, crackers, shortening, fried foods, and commercially baked items such as cookies and cake—are even worse, as they raise LDL and lower the helpful HDL. Used to keep manufactured foods fresh, trans fat frequently appears on product labels as “partially hydrogenated vegetable oil. ”
The American Heart Association suggests that trans fat be no more than 1% of total daily calories, and saturated fat make up less than 10% of total daily calories, though 7% is ideal if LDL is already high. Overall, total fat intake should be 25 to 35% of total daily calories. Here are some basic tips for a cholesterol-friendly diet:
1. Replace foods high in trans fats and saturated fats with foods containing “good” fats. Monounsaturated fats are found in peanut, canola and olive oils, as well as in avocados, pecans, almonds, and seeds. Polyunsaturated fats are found in fish (like salmon and mackerel), walnuts, and sunflower, corn, soybean, and flaxseed oil.
2. Go lean. Remove the skin from poultry. Avoid fatty red meat such as prime beef and pork cuts, as well as processed meats such as bologna and pepperoni. And don’t forget to switch to low-fat dairy products.
3. Load up on soluble fiber. Soluble fiber can not only lower LDL, it can bind to bile in the gut (which is made up of cholesterol), reducing the absorption of cholesterol in the intestine. Look for soluble fiber in oats, flaxseed, barley, dried beans and legumes, as well as in some whole-grain cereals, cereal bars and pastas. Word to the wise: take it slow. You don’t want difficulties in the bathroom.
4. Eat small frequent meals throughout the day. A study published in the British Medical Journal found that people who ate six small meals each day had an average cholesterol level that was 5% lower than those who ate only one or two big meals each day. The study also found that eating more frequently assisted in lowering levels of LDL.
Live a Cholesterol-Free Lifestyle
In addition to altering your diet, two other important ways to lower cholesterol are to exercise and to quit smoking. Everyone knows smoking leads to lung cancer and breathing issues, but not everyone understands that it’s also a major risk factor when it comes to atherosclerosis. A study conducted at University of Minnesota School of Public Health showed that smokers who kicked the habit could improve their levels of HDL within one year.
Exercise also helps by raising your HDL, though some workouts are more effective in this than others. The longer your aerobic workout (as measured by duration or distance), the better. If you’ve been sedentary, consider trying to get at least 30 minutes of moderate aerobic activity—such as brisk walking, swimming or dancing— every day.
All in all, it’s important to start committing yourself to a lifestyle that promotes lower cholesterol and good health. “If we could make Chattanooga the wellness capital of the Southeast, we would have an abundance of nature walk groups and people who understand how to buy groceries appropriately,” Dr. Wendt says. “It requires more than just an individual. It requires a whole culture.”
Pamela Perkins was a longtime staff reporter for The Commercial Appeal in Memphis, where she earned a Missouri Lifestyle Journalism Award and a Neighborhood USA Notable Award. She now lives in Chattanooga with her family.