This column is the third in a series related to heart disease — the number one killer of both men and women in the U.S., and a major cause of disability. Almost all heart attacks are preventable, and during February (“heart month”) Compass Peak Imaging in Glenwood is offering a discounted price for FDA-approved heart disease screening, using carotid IMT. There will also be a power point presentation about heart attack prevention at 7 p.m. on Feb. 15, at the Third Street Center in Carbondale.

Cholesterol is important in the formation of bile acids and some hormones, and is a component of cell membranes. It is synthesized by cells throughout the body, but particularly liver cells. Some also comes from dietary sources. While cholesterol is necessary for human life, high levels can cause gallstones and hardening of the arteries (atherosclerosis) — the cause of heart attacks, strokes and several other problems.

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A “cholesterol test” (also known as a “lipid test”) includes the level of total cholesterol; HDL (good cholesterol); LDL (bad cholesterol), and triglycerides. Think of your LDL as garbage in your arteries, so if you have too much garbage you’ll have a problem with your arteries. Think of HDL as garbage trucks, so you’ll also have a problem if you don’t have enough garbage trucks.

There are caveats with HDL, because some people have a low number of garbage trucks (low HDL), but the ones they have are super-charged, and these people have normal arteries. Other people have lots of garbage trucks (high HDL) but their garbage trucks are dysfunctional and cause rather than prevent disease.

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There are some caveats with LDL as well:

1. LDL particle number is more meaningful than the usually-measured level of LDL;

2. There is a particularly harmful type of LDL called Lp(a) (called “LP little a”) that is often present in families with lots of early heart disease;

3. Size of LDL particles matters — small, dense, BB-like LDL particles are particularly harmful, compared to large, fluffy, ping-pong-like particles. Blood tests that measure these things are inexpensive but often not done.

National cholesterol guidelines specify that ideal lipid levels are: total cholesterol less than 200; HDL greater than 40 in men and postmenopausal women, greater than 50 in premenopausal women; LDL less than 100, and less than 70 in people with a history of heart attack, stroke or diabetes; triglycerides less than 150.

However, half of people who have heart attacks and strokes meet these guidelines. Heart attack prevention doctors feel that — given that 20% of heart attacks victims die — if atherosclerosis can be demonstrated in a patient by studies such as a coronary calcium score (CT scan of the heart) or carotid IMT (ultrasound picture of the carotid arteries in the neck), LDL should be less than 70.

Plant-based providers feel that normal lipid levels should be seen in people who never develop atherosclerosis, and who are therefore heart attack-proof — such as people in the Blue Zones. These people have total cholesterol levels of less than 150; LDLs in the 30s and 40s; and triglycerides less than 70.

All animal products, especially eggs and including seafood, contain cholesterol, so to achieve optimal cholesterol levels these foods should be avoided. Furthermore, the saturated fat present in all animal products, in palm and coconut products, and in vegetable oils, cause the liver to produce more LDL. Over 30 years ago, Dr. Dean Ornish proved that heart disease can not only be prevented but can also be reversed with a plant-based, whole food diet with no salt, sugar or added oil. This diet is also one of the few things that lowers Lp(a).

Plant foods that are especially good at lowering cholesterol include high-fiber fruits and vegetables; legumes; unprocessed grains; and ground flaxseed. The following herbs and spices also lower cholesterol: Amla (1/2 teaspoonful of powder daily, which also lowers Lp(a); and ground black cumin 1/4 teaspoon daily. Red yeast rice contains a weak, natural statin that lowers cholesterol a little, but being a supplement is unregulated so you don’t know for sure what you’re getting.

Diet always helps lower lipid levels in everyone, but for genetic reasons in some people diet isn’t enough to achieve ideal lipid levels because their liver makes too much LDL no matter what they eat. For these people, and for people unwilling to change their diet, drug options are available: statins prevent the liver from making so much cholesterol; ezetimibe prevents absorption of cholesterol; and for people who don’t tolerate statins there are the newer but more expensive PCSK9 inhibitors, which are given by injection every two-four weeks.

Atherosclerosis can start in infancy, and the National Heart, Lung, and Blood Institute recommends that all children have a cholesterol screen between age 9 and 11, and again at 17-21. Obese children, children with a family history of very high cholesterol (called familial hyperlipidemia), and children with a family history of early heart disease are advised to get screened earlier than 9. Adults should have their cholesterol checked every five years starting at 20 — more often if their lipids are abnormal. Eating prior to a cholesterol test results in higher triglyceride levels, so heart attack prevention doctors recommend fasting (water only) for at least six hours before getting blood drawn to check lipids.

Dr. Feinsinger is a retired family physician with special interest in disease prevention and reversal through nutrition. Free services through Center For Prevention and The People’s Clinic include: one-hour consultations, shop-with-a-doc at Carbondale City Market, and cooking classes. Call 970-379-5718 for appointment, or email gfeinsinger@comcast.net

Dr. Feinsinger is a retired family physician with special interest in disease prevention and reversal through nutrition. Free services through Center For Prevention and The People’s Clinic include: one-hour consultations, shop-with-a-doc at Carbondale City Market, and cooking classes. Call 970-379-5718 for appointment, or email gfeinsinger@comcast.net.