Should You Be Worried About Your Cholesterol?
What Should Your Cholesterol Levels Be?
The idea that a cholesterol level should be under 200 dates back to before I was practicing medicine. Some smart scientists had noticed that people with high cholesterol had a higher risk of heart attack. More scientists got together and decided that, based on the evidence, 200 was a good cut-off point. To celebrate their decision, they went out to a dinner of bacon cheeseburgers and donuts.
OK, I'm not really sure about the celebration, but they did decide on 200 as the cutoff.
What are the Different Types of Cholesterol?
Some time later, some other scientists noticed that there are people with cholesterol over 200 who don't have heart attacks, whereas others with levels under 200 do. Their research showed that there are several types of cholesterol of varying density. They named these types of cholesterol High Density Lipoproteins, or HDL, Low Density Lipoproteins, or LDL, and Very Low Density Lipoproteins,or VLDL.
What is the Difference Betwen HDL and. LDL?
Anyhow, it turns out that a high LDL is associated with higher risk of heart disease while a high HDL is associated with a lower risk. The VLDL, which is mainly triglycerides, has a much smaller effect than the HDL and LDL, so we'll ignore it for now. LDL is commonly referred to as bad cholesterol, and HDL as good cholesterol. You have to wonder how long these politically-incorrect names will be used. LDL's self-image must be shot by now with all the praised being heaped on HDL.
Back in the science lab, some other scientists began to notice that a few people with high LDL didn't develop heart disease, and some with low LDL did. I say this only to point out that my explanation is a simplified one, and should not be taken as an exhaustive explanation. I also do it to point out how annoying some scientists can get if they have time on their hands.
When Should You Worry About Cholesterol?
So what about good old Ralph and his cholesterol over 200? Should he be worried? It's hard to say. Total cholesterol is calculated by using a formula that includes HDL, LDL, and triglycerides. That makes the overall cholesterol number of limited use to me as a doctor. It's kind of like if you asked someone for the score of a football game and they answered "42," adding together the scores of both teams. Technically, they are right in their answer, but the information is probably not what you want. You want to know the score of the good team and how it compares to that of the bad team.
In the same way, the LDL and HDL numbers are far more important to Ralph than the total cholesterol. In fact, there is a calculation called the Framingham Risk Score which uses HDL and LDL levels, along with other risk factors, and calculates a person's 10-year risk of having a heart attack. I'll put a link to this formula in the show notes.
When you get down to it, people don't die from high cholesterol, they die from heart attacks and strokes. If I knew a person with high cholesterol would stay healthy until they were 90, I wouldn't bother treating them. That is what makes the Framingham Risk Score useful to me: it focuses on what really matters. It's not a perfect formula, but it gives a decent idea of risk. My goal as a doctor is to get that 10-year risk as low as possible.
So what does this mean to you? Here are my quick and dirty tips about cholesterol:
Tip #1: Get Your Cholesterol Checked
It's important to know what your risks are, and since heart attacks are associated with higher LDL and lower HDL, it is good to know these numbers. This is especially important as you get older, as heart attacks get much more frequent as people age.
Tip #2: Don't Focus on the Total Cholesterol
Knowing your HDL and LDL will allow you to know your real risk. For low-risk people—or people without any risk factors (which I'll get to in my next tip) the goal is to have an LDL under 160. But that goal changes as the number of risk factors goes up. For people with diabetes, for example, the LDL should be under 70.
As for your HDL level, you want that to be over 40, although over 50 is even better.
Tip #3: Know Your Other Risk Factors
Knowing your risk factors for heart disease —aside from cholesterol-- will tell you how closely you'll need to monitor your cholesterol.
There are six major risk factors:
High Cholesterol
Smoking
Strong family history of heart disease in your immediate family
Advanced age
Additionally, men are generally at higher risk for heart disease than women are.
The family history needs to be put in perspective. If your uncle Harry had a heart attack when he was 90, it's doesn't really increase your risk, but if your father had a heart attack at age 40, you should be far more concerned about cholesterol. I don't treat cholesterol numbers without knowing the overall risk.
It's like hurricanes. If you live in Florida, you worry about hurricanes, keeping tabs on the weather and having a house that can withstand high winds and water. If you live in Idaho, on the other hand, you don't have to worry at all about hurricanes (although I guess your risk of being pelted with potatoes goes up).
Your doctor should figure out your real risk of heart disease. If he or she doesn't calculate your risk, do it yourself and show them the results.. Check out episode 37 for help on which tests diagnose heart problems.
Tip #4: Do What You Can to Have the Best Cholesterol Possible
There are many things you can do to lower your LDL and raise your HDL. These include:
Exercising (my QDT colleague, Get-Fit Guy, can help you)
Eating right (Nutrition Diva has great tips, including one specifically about using diet to lower cholesterol)
Not smoking.
Foods rich in saturated and trans-fats tend to raise the LDL, whereas foods rich in unsaturated fats can actually raise the HDL--the good cholesterol. In general, this means that you should minimize animal fats --- more common in red meats -- but don't cut back on vegetable fats. Olive and canola oils are rich in the good unsaturated fats, and so are actually good to have. Also avoid "hydrogenated" oils, which are fats that have been turned from unsaturated to saturated fats by food manufacturers. They do this to make its consistency better, but it makes the food much less healthy.
Read labels. Know what you are putting in your mouth. Again, The Nutrition Diva is an excellent resource on this if you want more information.
Tip #5: Consider Cholesterol-Lowering Drugs if You are at Increased Risk
I only use medications when I feel the risk of taking them is outweighed by the risk of not taking them. Studies have shown that bringing the LDL down with specific medications in high-risk people lowers the risk of heart disease and death. Which people and which medicines? That's what I did all my training to know. You'll need to see your own doctor to find out if these medications are appropriate for you. In general, though, I think a person with a 10-year risk over 10% should be considered for treatment and someone over 20% should clearly be treated.
Are Cholesterol Drugs Dangerous?
Are cholesterol drugs dangerous? I don't think they're dangerous, but they do have significant risks. That's why I have to have a license to prescribe them, and why they aren't in the grocery store next to the candied yams. All drugs should be used only when the benefit significantly outweighs the risk.
Ultimately, the decision is between you and your doctor. As the person taking the medication, you should be aware of the risk you take by taking the medication and also the risk of not taking it. There is, in my opinion, pretty strong evidence that using "statin" drugs can significantly improve the survival and quality of life of high-risk people.
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