Doctor’s Tip: High cholesterol damages arteries
Cholesterol is present in higher animals and is the precursor of bile acids and steroid hormones and is present in cell walls. It is sometimes present in gallbladder stones, and is always present in arterial plaque (atherosclerosis aka “hardening of the arteries”). When a “cholesterol test” is ordered, what the lab usually does is a “lipid panel,” which includes:
• Total cholesterol.
• HDL or “good” cholesterol (H for healthy).
• LDL or “bad” cholesterol (L for lousy).
Think of LDL as garbage in your arteries, so too much garbage in your arteries causes damage. Think of HDL as garbage trucks, so you will also have arterial damage if you don’t have enough garbage trucks. Meat, fish, dairy and eggs have cholesterol, and eating them raises your blood cholesterol. Saturated fat, present in meat, dairy, eggs and oils (including vegetable oils) causes your liver to make more LDL and raises your blood LDL level. Whether you eat these things or not, your liver makes all the cholesterol you need.
In spite of some unscientific skepticism, high total cholesterol and/or LDL clearly is one of the causes of atherosclerosis, which in turn causes heart attacks and strokes. For example, there is a genetic disease called familial hyperlipidemia, where people have extremely high total cholesterol and LDL. Without aggressive treatment these people die at a young age (even as teenagers) of heart attacks.
The U.S. cholesterol guidelines say that we should aim for these levels of cholesterol:
• Total cholesterol less than 200.
• LDL less than 100, and less than 70 if you’ve had a heart attack.
• HDL greater than 40 in a male or postmenopausal female, greater than 50 in a premenopausal female.
• Triglycerides less than 150.
However, as with most guidelines, there are issues with the cholesterol guidelines:
• “Normals” are based on values for the average American, and the average American will die from a heart attack eventually.
• Less than 50 percent of the guidelines are based on hard science; the committees that form them have members with ties to the food and pharmaceutical industries; the guidelines are always a compromise; and by the time they come out they are 10 years behind the cutting edge science.
• Given that 20 percent of heart attacks result in sudden death, heart attack prevention doctors say that rather than waiting until someone has a heart attack to get their LDL less than 70 we physicians should do that if we identify even a small amount of plaque in someone, since anyone with plaque is at risk for a heart attack or stroke.
Half of people who have heart attacks have normal lipid panels. Here’s why:
• What we should be calling normal for total cholesterol and LDL should be based on the levels in people who never develop atherosclerosis and therefore never have heart attacks or strokes. These are people who eat a lifelong plant-based, whole food, low fat diet, such as the Seventh-day Adventists, who for religious reasons are plant-based.
• These people have total cholesterols less than 150, LDLs in the 30s and 40s, and triglycerides less than 70. Their HDL tends to be low but although they have few garbage trucks, their garbage trucks are superefficient.
• It’s not all about cholesterol: inflammation plays a role in formation of atherosclerosis and in causing heart-attack-causing plaque rupture.
• A more meaningful test than LDL level is LDL particle number, and the size of the LDL particles is important (bigger is better).
• Lp(a) is a particularly harmful type of LDL particle and is frequently the driver of atherosclerosis in families with early heart disease, and should be measured.
Next week’s column will discuss treatment of high cholesterol.
Dr. Feinsinger, who retired from Glenwood Medical Associates after 42 years as a family physician, now has a nonprofit Center For Prevention and Treatment of Disease Through Nutrition. He is available for free consultations about heart attack prevention and any other medical concerns. Call 970-379-5718 for an appointment. For questions about his columns, email him at firstname.lastname@example.org.
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