High Cholesterol

"My doctor says my 'bad' cholesterol is too low - is this good or bad?"
"You mean your 'good' cholesterol is too low, right?"
"Yes, I guess so. Can you please explain to me which cholesterol numbers I need to know?"
My patients routinely hand me the blood work printout they received from their doctor and ask me to translate the numbers, as they are baffled by the alphabet soup associated with heart health. True, there are myriad factors that increase your risk for heart disease, such as family history, smoking, and high blood pressure. Other factors that increase your risk will be evident from your blood work: high total cholesterol, low HDL cholesterol, high LDL, high triglycerides, a high ratio of total cholesterol to HDL, a high number of small, dense LDL particles, and so on.

The most important number: LDL

     To streamline an otherwise complex topic for my patients, and for the purposes of this book, I recommend (with loads of science to substantiate this approach) that you familiarize yourself with one particular number above even your total cholesterol number - the "bad" LDL cholesterol - and leave the remaining values for your primary care physician to interpret. Learning to pay attention to this one number will not only make things easier, it will give you greater control in monitoring your risk for heart disease. If tracked over time, your LDL cholesterol will provide you with a clear and highly motivating snapshot of how your lifestyle changes are positively affecting you.

What is the rationale for targeting LDL?

     There are five strong arguments for targeting LDL: (1) It is just plain easier to focus on one representative number. Like stepping on a scale to check your progress on a weight loss program, measuring LDL helps you assess your cholesterol level. (2) The nation's top two heart health agencies - the American Heart Association and the National Heart, Lung, and Blood Institute - specify lowering LDL as the primary therapeutic aim for individuals with high cholesterol. (3) Decades of scientific evidence derived from both human population studies and animal research demonstrate a link among high cholesterol, high LDL cholesterol, and heart disease. (4) Two Nobel Prize - winning scientists, Michael S. Brown and Joseph L. Goldstein, demonstrated the danger caused by too much circulating LDL in the blood. (5) Recent intervention studies utilizing powerful statin drugs have shown that lowering LDL saves lives, prevents new heart problems, and even reverses plaque buildup.

                                                                                                          Keep it simple

     The most obvious reason to focus on LDL cholesterol is that it is simpler to track one representative value rather than wade through all the values associated with heart disease.

     Equate this concept with losing weight and stepping on a scale. One could analyze the percentage of body fat, calculate body mass index, or take circumferential measurements to reflect change in body composition. Most of my patients don't want to do that. They prefer the easiest and quickest method of getting feedback regarding the efficacy of their weight loss efforts: stepping on a scale. One, two, three ... they either lost weight or they didn't! I tell them to weigh themselves once a week and let me do the rest of the calculations.

     The same can be said for cholesterol: focus on your LDL cholesterol number and let your physician test for and interpret the myriad of additional values associated with your risk for cardiovascular disease. Targeting and reducing your LDL cholesterol number will diminish your chances of cardiovascular disease, may even shrink plaque buildup, and will help stabilize vulnerable plaque if the process of atherosclerosis has already advanced to this precarious stage in your arteries.

     Above all else, you must know your LDL number and understand that with lifestyle changes, such as the Cholesterol Down Plan, this is a number you can control and lower to reduce your risk for cardiovascular disease.

Heart health agencies come down on LDL

     In 1985, amid an epidemic of cardiovascular disease in the United States, the government's National Heart, Lung, and Blood Institute (a division of the National Institutes of Heatlh) mounted an aggressive campaign to educate the public about the connection between high blood cholesterol and heart disease, called the National Cholesterol Education Program (NCEP). NCEP has clearly succeeded in its goal of educating Americans about the health risk of high blood cholesterol. What's needed now is a clear and concise message that the LDL cholesterol value is the single most important number for the public to know.

     To increase citizens' awareness of the danger associated with high LDL, several of the nation's top heart health agencies have stated in their official guidelines that reducing LDL cholesterol is associated with reduced risk for heart disease.

     A paragraph in the NCEP patient handout "HIgh Blood Cholesterol - What You Need to Know" reads: "The main goal of cholesterol - lowering treatment is to lower your LDL enough to reduce your risk of developing heart disease or having a heart attack. The higher your risk, the lower your LDL goal will be.

What the top dogs have to say

In 1988, NCEP convened an expert panel that set out to review the latest scientific data and publish a report containing treatment recommendations for physicians. This report, titled Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (or ATP I), became the bible for determining how doctors should categorize and treat their patients at risk for heart disease and stroke. According to the most recent NCEP clinical practice guidelines on cholesterol management (ATP III), LDL has long been identified by NCEP as the primary target of cholesterol - lowering therapy," a focus that "has been strongly validated by recent clinical trials" in that they have shown that significantly lowering LDL indeed reduces the risk for coronary heart disease. In addition, "a broad base of evidence indicates that elevations in LDL cholesterol are a direct cause of atherosclerosis. Long-term elevations of LDL lead to a progressive accumulation of coronary atherosclerosis," which is a precursor to heart attacks or stroke.

     According to the recent update on the ATP III panel guidelines, "all ATP reports have identified low-density lipoprotein cholesterol (LDL-C) as the primary target of cholesterol - lowering therapy," a statement supported by many large-scale studies that clearly show that a high amount of LDL in the blood is "a major risk factor for coronary heart disease (CHD)." Furthermore, a large number of smaller intervention studies have documented that lowering the amoung of LDL in the bloodstream reduces the risk of a major heart attack.

     The American Heart Association Dietary Guidelines Scientific Statement concurs with NCEP, warning that "high total and LDL cholesterol levels are strongly related to coronary artery disease risk and that reductions in LDL levels are associated with reduced coronary disease risk." The American Heart Association further recommends that all Americans take "dietary measures aimed at maintaining desirable LDL cholesterol levels, as defined by the current guidelines of the National Cholesterol Education Program (NCEP).

Highlights of ATP III½

     The government recently published an update to the 2001 ATP III report, familiarly known in scientific circles as "ATP III ½." The update includes a new "very high risk" category as well as a record ultra-low LDL target for those individuals in this category (LDL less than 70 mg/dL).

     The Cholesterol Down Plan can be very useful for people in this highest-risk category as an adjunct to statin treatment. I've included most-therapeutic doses for some of the steps that will aid you in reaching this ultra-low LDL target.

Source: Cholesterol Down, Foreword by Jennifer H. Mieres, M.D.