Doctor’s column: The dirty details on cholesterol
ABOUT THIS COLUMN
Greg Feinsinger of Carbondale, who retired in February from Glenwood Medical Associates after 41 years as a family physician, is writing a 10-week series of columns on critical health issues for the Post Independent. The columns will appear in Tuesday’s Body & More pages.
Usually when doctors talk about “cholesterol,” they are referring to lipids, which include total cholesterol, HDL or “good” cholesterol (think H for healthy), LDL or “bad” cholesterol (think L for lousy), and triglycerides.
High total cholesterol and/or high LDL and/or high triglycerides has a proven relationship with increased risk for heart attacks and strokes. There is also an inverse correlation between HDL level and cardiovascular events (the lower the HDL, the higher the risk, low being considered anything less than 40 for men and for post-menopausal woman and less than 55 for pre-menopausal women).
However, half of people with heart attacks have “normal” lipids, particularly total cholesterol and LDL. This is why:
1. The wrong thing has been measured all these years. LDL refers to the level of LDL, but what is much more important is the number of LDL particles, which can be easily measured at little added cost. So a person with multiple small, dense, BB-like LDL particles and a person with a lower number of large, ping pong-like particles will have the same LDL measurement, but the former person will be at much higher risk.
2. The usual lipid panel does not include the most dangerous kind of LDL, called Lp(a). This also can be measured easily and cost-effectively, but is seldom ordered by health care providers.
3. What we call normal is based on average levels for people on the SAD (Standard American Diet), and is not really normal. We consider a total cholesterol of less than 200 and an LDL of less than 100 as really good. However, people in the world who never get atherosclerosis (hardening of the arteries, which is what causes heart attacks and strokes) have total cholesterols below 150 and LDLs in the 30s and 40s. Newborns have levels like that, as do other mammals that don’t get atherosclerosis, so that is what we should consider as normal.
4. Atherosclerosis/heart attacks and strokes are not all about cholesterol — other factors such as inflammation can play a role.
Think of LDL as garbage in your arteries, so if you have too much garbage you will have a problem with your arteries. Think of HDL as garbage trucks, so you will also have problem if you don’t have enough garbage trucks.
Scientists have LDL pretty well figured out, but HDL is still poorly understood. For example, some people have very low HDLs and still don’t get atherosclerosis. They seem to have super-efficient garbage trucks.
Also, we used to tell patients that if they had an HDL of 70 or over, they were not at risk, but now we know that isn’t true, and that some people have high but dysfunctional HDL that can actually cause atherosclerosis.
Finally, drugs such as niacin that raise HDL have not been shown to prevent cardiovascular events.
Statin drugs are good at lowering total cholesterol and LDL, and are about 30-40 percent effective at preventing heart attacks and strokes (probably through their anti-inflammatory effect more than anything).
However, being drugs, they can have side effects. Lifestyle modification in the form of regular exercise and a plant-based, whole (unprocessed), low fat diet is at least 90 percent effective and some studies show 98 percent effective at preventing events.
The people in the world who never get atherosclerosis (see No. 3 above) are on this diet, sometimes by choice, sometimes because that’s all they can afford. And lifestyle modification has no side effects and is free.
Dr. Feinsinger is a retired family physician who is available for free consultations about heart attack prevention, plant based nutrition, and other health issues. Call 379-5718 for an appointment.
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