Doctor’s Tip: What you need to know about cholesterol
December 4, 2017
Cholesterol is the precursor of bile acids and steroid hormones and is a constituent of cell membranes. We need cholesterol, but high levels cause problems. Most of our cholesterol is produced by our liver, but some comes from food we eat. A typical cholesterol test, called a "lipid panel," includes a total cholesterol; LDL (L for lousy) cholesterol; HDL (H for healthy) cholesterol; and triglycerides. I tell patients to think of their LDL as garbage in their arteries and HDL as garbage trucks — they will have a problem with their arteries if they have too much garbage or too few garbage trucks. Some doctors tell their patients that they don't have to fast to have a lipid panel drawn, but triglycerides tend to be high in the non-fasting state, so I tell my patients to fast for six hours (water is OK).
There are cholesterol skeptics out there who claim on the internet and elsewhere that high cholesterol is not related to disease, but this belief is not based on sound science. High cholesterol and especially high LDL are clearly associated with atherosclerosis ("hardening of the arteries"), which is the cause of heart attacks; strokes; peripheral vascular disease (blockages in leg arteries); chronic kidney disease; erectile dysfunction; and dementia. Cholesterol is found in arterial plaque, and electron microscope photos show cholesterol crystals poking through the capsule that surrounds plaque, causing plaque rupture, resulting in heart attacks and strokes. There is a genetic abnormality called familial hyperlipidemia, where sufferers have extremely high cholesterol levels, and some children with this disease die in their teens from heart attacks.
On the other hand, half of people with heart attacks have normal cholesterol. The U.S. guidelines recommend that normal total cholesterol levels should be less than 200; LDL less than 100; triglycerides less than 150; HDL greater than 40 in a male or post-menopausal female; and HDL greater than 50 in a pre-menopausal female.
The guidelines also recommend that if a person has had a heart attack their LDL should be less than 70. Heart attack prevention doctors (who with some exceptions aren't cardiologists) disagree with the latter guideline, because around 20 percent of people die from their first heart attack. Therefore, we advise patients to have a carotid IMT or coronary calcium score to see if they have plaque in their arteries. If they do, they are at risk for a heart attack or stroke and we recommend an LDL of less than 70.
Populations who are on a lifelong plant-based, whole food diet with no salt, sugar or added oil don't get atherosclerosis and therefore are heart attack proof. Their total cholesterols are less than 150, LDLs are in the 30s and 40s, and triglycerides less than 70. These are the levels in human newborns and in other mammals that don't get atherosclerosis. So those are the levels plant-based doctors want in our patients.
The usual lipid panel measures the level of LDL, but a more meaningful measurement is the LDL particle number (the number of LDL particles per unit of blood). Also, small, dense LDL particles are more dangerous than large ones. Another blood test that heart attack prevention doctors always order is Lp(a), which is a particularly harmful type of LDL that responds to niacin and to a plant-based diet, but not to statins. Finally, heart disease is not all about cholesterol — inflammation plays a role, particularly inflammation due to tooth or gum disease. Heart attack prevention doctors often order an "advanced lipid profile" through the Berkeley or Cleveland Heart Lab, which includes all the above tests plus inflammatory markers that measure inflammation of the endothelial lining of the arteries and of plaque (MPO and LpPLA2, respectively). The commonly ordered hsCRP — highly sensitive C-reactive protein — is a nonspecific test for inflammation anywhere in the body.
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Your liver makes more LDL if you eat saturated fat found in oils and in animal products. A plant-based diet improves lipid levels, often dramatically, and more importantly this diet is at least 90 percent and most studies show 98 percent effective in preventing heart attacks. Statins prevent the liver from making so much cholesterol, lower cholesterol and LDL significantly, but are only 30 percent effective in preventing heart attacks. If triglycerides are even mildly elevated and HDL on the low side, diabetes or pre-diabetes are almost always the cause.
In their book "Beat the Heart Attack Gene," Bale and Doneen recommend that anyone with plaque in their arteries take a statin drug, no matter what their total cholesterol or LDL are. If you don't want to do that or have had side effects from statins, try Amla (Indian gooseberry), which has been shown to be very effective in lowering cholesterol, inflammation and blood sugar. (Search Amla on Dr. Greger's website nutritionfacts.org.) Order Amla on the internet, but be sure it's organic and from a reputable company.
Dr. Feinsinger, who retired from Glenwood Medical Associates after 42 years as a family physician, 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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