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May 16, 2001 -- The National Cholesterol Education Program's new guidelines for cholesterol management are sure to fuel many questions. We answer a few common ones here:
Q: What exactly is cholesterol?
A: Cholesterol is a waxy, fat-like substance found in animal foods, such as meat, fish, poultry, eggs, and whole-milk dairy products. It also is produced in the liver. Every cell in the body needs some cholesterol -- it is vital for many of the body's functions. However, if you have too much, it builds up in your blood and clogs arteries, which can put you at risk for heart disease, heart attack, and stroke.
Q: I thought that only middle-aged and older people needed to have their cholesterol levels checked, but now I'm hearing that cholesterol can be a concern even in young people. Please explain.
A: It's true that most heart disease occurs in middle-aged and older people. But the artery-clogging "plaques" that can lead to a heart attack or stroke begin to develop long before a person has any symptoms -- maybe even as early as the teens or 20s. Increasing evidence suggests that young people with heart disease risk factors -- such as high blood pressure and high cholesterol levels -- are more likely to develop heart disease as they age than young people who don't have these risk factors. This suggests that people should start having their cholesterol levels checked at a younger age than most doctors have recommended in the past.
In fact, the current recommendations urge everyone aged 20 and older to have complete cholesterol testing after an 8-hour fast done every 5 years. Many of us know our total cholesterol level -- the level that is supposed to be below 200. But now we need to know much more about our cholesterol levels. That means knowing the levels of your total cholesterol, LDL (bad) cholesterol, and HDL (good) cholesterol.
Of course, if you have other risk factors for heart disease, your doctor may recommend even more frequent testing. It is very important to know what your heart disease risk is and then determine, in consultation with your doctor, what lifestyle changes or even drug therapy may be appropriate for you -- regardless of your age.
Q: I'm still confused about the differences between "good" and "bad" cholesterol.
A: Cholesterol is transported in a person's blood in special proteins called lipoproteins. The two we are most familiar with are low-density lipoprotein (LDL cholesterol) and high-density lipoprotein (HDL cholesterol). LDL is often referred to as "bad" cholesterol. It transports cholesterol from the liver to other body tissues -- depositing excess cholesterol on the walls of arteries to form artery-clogging "plaques" that contribute to the development of heart disease and stroke. You want to have less of this.
In contrast, HDL, or good cholesterol, helps remove excess cholesterol from the blood -- transporting it back to the liver, where it can be eliminated from the body. You want to have more of this type.
Q: I just got back my cholesterol profile. What numbers do to I need to look for?
A: The cholesterol numbers in your blood profile reflect the amount of cholesterol (both LDL and HDL) as well as a type of fat called triglycerides in your blood stream. In general, high blood levels of total cholesterol are associated with an increased risk of heart disease. However, a person's actual risk also depends on the proportions of LDL and HDL in the blood. Your risk of developing heart disease is increased if you have either (1) a high LDL level, (2) a low HDL level, or (3) a high LDL-to-HDL ratio.
The latest recommendations are that LDL levels ideally be below 100 -- a significant reduction from previous recommendations -- and that HDL levels be above 40, ideally over 60.
Q: I've heard that I can improve my cholesterol numbers by changing my diet. Can you give me some tips on doing that?
A: The guidelines recommend eating a diet that is low in saturated fats, trans-fatty acids, and cholesterol.
Foods rich in cholesterol and saturated fats -- such as meats, whole milk, eggs, butter, lard, and many bakery products -- increase your risk of heart disease and stroke by raising the levels of LDL cholesterol in the blood, which contributes to the development of artery-clogging plaques.
Trans-fatty acids, the so called "trans fats," are found in margarines, vegetable shortenings, and commercially baked breads, cakes, cookies, and crackers -- as well as French fries. They are as bad as saturated fat in increasing the risk of heart disease, so you should limit your consumption of them.
Monounsaturated fats, such as those in olive and canola oils, may slightly reduce blood cholesterol when they replace saturated fats in the diet, but still, they should be taken in moderation. Polyunsaturated fats, or the "good-for-you" fats, do not appear to contribute to heart disease risk and may in fact prevent heart disease. Fish like salmon, tuna, mackerel, trout, and sardines contain these good fats.
Q: Besides diet, what else can I do to improve my cholesterol levels?
A: Increase your physical activity. Aerobic exercise -- such as walking, jogging, bicycling, or swimming -- can increase your HDL cholesterol levels. Even 30 minutes of brisk walking every other day can help. If you smoke, quitting may increase your HDL levels -- and reduce your heart disease risk in other important ways. If you are overweight, losing weight also improves cholesterol levels, and some studies suggest that drinking one or two small alcoholic drinks a day can raise your HDL cholesterol.
Talk with your doctor before making any changes in your physical activity.
Q: I've done all that, and my doctor is still telling me I have abnormal cholesterol levels. What happens next?
A: At this point, your doctor is likely to recommend medicines to improve your cholesterol profile. These drugs lower your blood levels of total and LDL cholesterol, while often increasing your levels of HDL cholesterol. By doing this, cholesterol-lowering drugs can help prevent or reduce the plaque buildup in blood vessels that can lead to a heart attack or stroke. A recent study has shown that cholesterol-lowering drugs also can help reverse cholesterol-related changes in blood vessels that occur before any signs and symptoms of heart disease. Some different types of cholesterol-lowering drugs include:
Q: What if a person has already had a heart attack? Is it too late to lower blood cholesterol?
A: No, it's not too late. People who have had a heart attack can reduce their risk of having future heart attacks and of dying from heart disease by taking cholesterol-lowering drugs, such as statins. This may hold true even if the person's blood cholesterol level is in the normal range.
In addition to the long-term benefits of lowering cholesterol levels, statins appear to have short-term benefits after a heart attack. A recent study showed that people with heart attacks who were already taking a statin -- or who started taking one within 24 hours after going to the hospital -- were less likely to die in the hospital than those who did not take a statin.
Q: I have low levels of both "bad" (LDL) and "good" (HDL) cholesterol." Should I be taking a cholesterol-lowering drug?
A: Possibly. Research has shown that low HDL cholesterol is an important risk factor for heart disease -- even when LDL cholesterol also is low. What's more, the results of a recent study suggest that people with heart disease who have low levels of both LDL and HDL can reduce their risk of having a heart attack by taking a cholesterol-lowering drug. The drug used in the study, Lopid, increased the patients' HDL levels, without further decreasing their already low LDL levels. If you're concerned about your levels of either "good" or "bad" cholesterol, talk to your doctor. He or she can assess all of your heart disease risk factors and, if necessary, tell you what you can do to change them.
Q: What about women and older people? Is it really necessary to reduce heart disease risk as aggressively as middle-aged men?
A: Yes! Although women tend to get heart disease later than men, it is still the leading cause of death in women. Experts recommend that heart disease prevention efforts be as aggressive in women as in men. Also, although some research has shown that hormone replacement therapy in postmenopausal women may reduce heart disease risk, newer studies have put these observations into doubt. While doctors sort this out, you should not consider yourself to have a lower risk of heart disease if you are on hormone replacement.
Studies have shown that lifestyle changes and drug therapies to prevent heart disease are very effective in the elderly, and current recommendations are to aggressively reduce heart disease risks in all age groups.
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