What You Need to Know About Cholesterol
The Cholesterol Lowdown
I was a little surprised by the response when my boss took
an informal poll during a recent staff meeting. "How many of you know
your cholesterol numbers?" she asked the roomful of mostly women. About a
third of the hands went up. Then I jumped in and asked, "How many of
you really understand what those numbers mean or how to change them?"
Every hand went down.
So, if a bunch of
research-oriented journalists don't know what to do with all their data,
we thought, how can we expect our readers to know? We asked our
Facebook fans the same questions and they posted answers such as this
one: "I never really understood the numbers and how they work. I just
eat my Cheerios." In fact, only about 21 percent of women 18 to 44 know
their total cholesterol level, according to a 2007 survey by the Society
for Women's Health Research. And just under 14 percent know their LDL
("bad") cholesterol level, while only 12 percent know their HDL ("good")
cholesterol number. That backs up a previous Harris Interactive survey,
which found that 81 percent of women 50 and older don't know their LDL
or HDL numbers -- and nearly a quarter of those respondents had actually
suffered a heart attack or stroke or had diabetes.
Most
doctors don't have time to sit down with you and explain your lab
results in detail, so many women never learn the true extent of their
risk for heart disease, or how to prevent it. Heart disease is still the
number one killer of men and women, and women are less likely than men
to have their cholesterol levels under control, according to a large
analysis of managed-care and Medicare plans.
We realized it was time to get back to basics. So we consulted two top experts from our LHJ
Medical Advisory Board: Michael F. Roizen, MD, chief wellness officer
at the Cleveland Clinic, and cardiologist Holly S. Andersen, MD,
director of education and outreach at the Ronald O. Perelman Heart
Institute at New York City's New York-Presbyterian Hospital, to fill in
the blanks.
Total Cholesterol
What's ideal: Under 200
First,
cholesterol isn't technically the same thing as fat. Cholesterol is a
soft, waxy, fatlike substance mainly produced by the liver. And it's not
inherently bad; in fact, it's vital to all kinds of bodily processes,
from keeping cells healthy to making hormones. But sometimes the body
cranks out more cholesterol than you need, and the things you eat, what
you weigh, and the way you live can add even more, putting you at risk
for heart disease. But improving your diet, losing weight, and
increasing your exercise can reduce those risks, so keep reading.
We've
learned a lot about cholesterol in the past 20 years, says Dr.
Andersen, and what we know is constantly evolving, too. "When I was in
medical school, for example, we were taught that having a total
cholesterol number of less than 250 was normal, and we didn't even know
what HDL and LDL were. Today I still look at total cholesterol, and we
know we want it to be under 200, but HDL and LDL are much more
important."
The Bad Guy: LDL
What's ideal: Under 100
It stands
for low-density lipoprotein, but you can just remember the "L" stands
for "lousy," says Dr. Roizen. LDL circulates through your bloodstream
and deposits cholesterol in the walls of your blood vessels. This
actually starts when you're young; you get little deposits of the fatty
stuff here and there. Over the years it can build up, and other stuff
traveling through your bloodstream, such as waste products or calcium,
gets stuck on there, too. All this gunk combines to form plaque, which
can cause blockages, chest pain, shortness of breath, or a heart attack
(see "How Plaque Can Become a Heart Attack" on the next page). To
prevent plaque, you generally want to get your LDL as low as it can go.
What Moves the Needle
If you're overweight, the most important thing you can do to reduce your LDL is lose weight,
says Dr. Roizen. You should especially focus on your waistline. "The
fat around your belly releases proteins and hormones that can make your
LDL higher and raise your blood pressure and your risk of diabetes,"
says Dr. Andersen. That means cutting the simple-carb calories that go
right to your belly -- sugary stuff like sodas, candy, cakes, white
breads, rice, and pasta.
Processed foods containing
trans fats are harmful, too. Fish oils and plant fats tend to be okay.
If you're not overweight and don't have a big waist but your LDL is
still high, then you need to try lowering your intake of meat and dairy
products, too, says Dr. Andersen. It can be tough to eat an almost vegan
diet, she says, but those who do it really see a dramatic reduction in
their LDL. Working out more is also effective. When lifestyle efforts
don't reduce your LDL enough, your doctor will probably suggest that you
go on statin drugs (see "Who Should Take Statins?" on the next page).
The Good Guy: HDL
What's ideal: Over 50
HDL, or
high-density lipoprotein, can actually take some of the LDL from your
plaque and return it to your liver, where it's processed and disposed
of, says Dr. Roizen. Not only does HDL help
prevent new gunk from accumulating in your arteries, it can reduce
what's there. Women tend to have higher HDL than men do. But the
benefits of a high HDL level don't cancel out the bad effects of a high
LDL level, says Dr. Andersen. You have to work on improving both numbers
to really make a difference in your heart health.
What Moves the Needle
HDL
is much more difficult to manipulate than LDL, but experts agree that
aerobic exercise is key. "It can take a lot of physical activity, like
running a few miles a day, to really bring up your HDL level," Dr.
Andersen says. "But any amount of physical activity can improve the quality of your HDL, so that it works better."
"We
don't have really good data on this yet," says Dr. Roizen. "But it
appears that a little more intense aerobic exercise is much better than a
lot of milder exercise. You need to raise your heart rate, but whether
you get there from doing cardio or from intense weight training that
gets your heart rate up doesn't seem to matter."
Taking
niacin (vitamin B3) supplements has also been shown to increase HDL and
decrease the risk of stroke and heart attack. Dr. Andersen suggests
that you talk to your doctor first to determine the right dose. One side
effect to watch for: Niacin can make you flush. Taking it at night may
help; so can taking a baby aspirin or 325-mg adult dose aspirin 30
minutes before taking the niacin. Aspirin also has anti-inflammatory
effects that can help your heart, but it can cause bleeding problems, so
ask your doctor before you take it.
As for food,
omega-3s, which are in walnuts, fish oil and algal DHA supplements, can
raise HDL, says Dr. Roizen. A moderate amount of alcohol may raise your
HDL, too. "I don't tell women who don't drink to start drinking,
but one drink a day or maybe two has been shown to improve
cardiovascular health in women and improve their HDL," says Dr.
Andersen. But alcohol can also increase your risk of breast cancer, so
you have to factor in your family history and other risks.
The Scoop on Triglycerides
What's ideal: Below 100
Triglycerides
are the third part of the cholesterol equation. They are basically fats
-- from foods you've eaten or made by the liver -- carried through the
bloodstream to be stored in your tissues. A high level increases your
risk of coronary artery disease and diabetes. While some guidelines say
150 is normal, Dr. Roizen says that's too high and you should aim for
under 100. "Too often 'normal' means heart disease," he says. The
triglycerides number really reflects what you've been eating lately. To
get the most accurate reading, eat as you normally do in the week or so
before you get your cholesterol tested. Don't cut out lots of fat in an
attempt to fool the test, because it won't help you assess your real
risks. Dr. Andersen says your level also has a genetic component, and
sometimes very thin, seemingly healthy women can have a very high
triglyceride level.
What Moves the Needle
Triglycerides
respond very strongly to dietary changes, says Dr. Roizen. Reducing
those simple carbs that quickly turn to sugar (and hit your waistline)
is most helpful. Cutting animal fat and increasing exercise can help,
too. Although moderate alcohol intake can help raise your HDL, which is
good, it will also raise your triglycerides, which is bad. If your
triglycerides are high, Dr. Andersen says reducing your alcohol
consumption is important.
What's this ratio I'm hearing about?
Lab results may include a ratio that's calculated by
dividing your HDL level into your total cholesterol number. If you have a
total cholesterol of 200 and an HDL of 50, that's 200/50, or a ratio of
4:1. While many guidelines say the ideal ratio is 3.5:1, Dr. Roizen
says an optimal number is unknown and may be more like 2:1. Assessing
your actual numbers is more important, according to the American Heart
Association. Dr. Andersen says that although people are talking about
their ratio now, most experts have moved past it. "I never look at ratio
anymore," she says. If you have a high enough HDL you can get a
deceptively good ratio. Say you have an HDL of 65, which is good, and a
total level of 235. Your ratio would be an acceptable 2.6:1, yet you
could still have an LDL of 158 or 170, which is too high. "I wouldn't
ignore those LDL numbers," says Dr. Andersen. "You want your LDL as low
as possible."
How Plaque Can Become a Heart Attack
At first plaque looks like chicken fat, says Dr. Andersen.
As it grows it can obstruct blood flow and cause patients to say things
like, "Every time I walk up the stairs now I get chest pain." Worse, as
the blood is pounding over this fatty plaque, the plaque can get
inflamed and then rupture, which causes a blood clot to form in an
attempt to heal the rupture. The clot can then grow or break away and
cause a blockage and thus the need for angioplasty (where a balloon is
inflated via a catheter to widen the blocked artery), stents (a metal
mesh tube that is inserted after the blocked artery is opened by
angioplasty), or bypass surgery (where a vein from the leg or other part
of the body is surgically routed around the blockage). If the blockage
totally stops blood flow to your heart (as in the image, left), you'll
have a heart attack -- even if you've never had symptoms before. Dr.
Andersen says a 49-year-old patient of hers who was a marathon runner
had a heart attack from just the tiniest bit of fatty plaque. "We can't
predict when plaque is going to rupture. Sometimes the first symptom of
heart disease is death, and that's why we have to practice prevention."
Who Should Take Statins?
Many women can improve their numbers and decrease their risk of heart attack with exercise, weight loss,
and eating right. But sometimes willpower is not enough, or despite
your best efforts, your stubborn genetics keep your numbers in the red
zone. That's when your doctor might suggest you go on a statin. These
drugs inhibit an enzyme that controls cholesterol production in the
liver. Most statins can lower your LDL significantly and certain ones
may raise HDL, too. Statins also have an anti-inflammatory effect that
may be as important as their effects on cholesterol for preventing heart
disease.
Still, women are less likely to take statins
than men, despite being just as much at risk, said a 2008 study from
Rush University Medical Center. "In general in this country, we
underestimate the risks in women and don't treat them as aggressively as
we should," says Dr. Andersen. "And once a woman is diagnosed with
heart disease, she is more likely to die from it than a man is." Deaths
due to heart disease are continuing to increase in young women, which
makes prevention more important than ever. "These are lifesaving drugs
that are extraordinarily safe," she says. "I know there's a lot of
mistrust about prescription drugs, but these medicines have been used
successfully for decades and we've found that women on statins are
living longer, with fewer strokes and heart attacks."
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