Now that we’ve discussed a primer on what cholesterol is, what’s “good” and “bad”, and the desired levels we look for in patients here at Triangle Family Care family practice in Cary, NC, let’s discuss what can be done to improve cholesterol.
Q. What can be done to improve cholesterol so that the risk of atherosclerosis is reduced?
A. There are many things that can be done to reduce “bad” cholesterol and raise “good” cholesterol to reduce the risk of premature atherosclerosis and the subsequent damage atherosclerosis can cause.
- The simplest, least expensive and most natural way to improve cholesterol is to eat better and eat less. The fewer calories consumed, in general, the lower the total cholesterol will be as there aren’t a lot of extra calories that can be turned into cholesterol or fat. The less cholesterol consumed will also lower the total cholesterol. Foods that most raise cholesterol levels are saturated fats (saturated fats are solid at room temperature – like butter, meat fat) and simple carbohydrates (simple carbohydrates start out white – like sugar, flour, rice, white potatoes). Remember that no vegetable has cholesterol, but there are calories and carbohydrates in vegetables.
- Another inexpensive and natural way to improve cholesterol is to exercise! Exercise burns calories so that there are fewer calories to be turned into cholesterol and exercise raises HDL as well.
- Believe it or not, alcohol, in moderation, can raise HDL too! For women, that’s no more than 1-2 servings of alcohol per day and in men, that’s no more than 2-3 servings per day. The best alcohol is probably red wine as it also has higher amounts of an antioxidant called resveratrol, though all alcohol will work. However, alcohol has calories that can contribute to excess calories and any alcohol in excess can cause more problems than having low HDL.
- Statin medications like Zocor (Simvastatin), Lipitor (Atorvastatin), Crestor (Rosuvastatin), Pravachol (Pravastatin), Mevacor (Lovastatin) and Lescol (Fluvastatin) block the enzyme HMG-COA reductase so that less cholesterol is manufactured by the liver cells. These are very effective and have been shown in many studies to reduce the risk of death, heart attacks and strokes. The most common side effects are muscle aches, elevated liver function tests, slight elevation of glucose levels and memory impairment. Statins are oral medications.
- Bile Acid Sequestrant medications like Welchol (Colesevelam), Colestid (Colestipol) and Questran (Cholestyramine) irreversibly bind bile acids (and the cholesterol those contain) in the gut to prevent reabsorption in the small intestine and are excreted in the stool. These are also oral medication.
- Zetia (ezetimibe) is the only medication in a class of drugs that block the reabsorption of cholesterol from the small intestine at the lining of the small intestine called the brush border. It does not bind cholesterol, but keeps it from being reabsorbed and then is excreted in the stool. This is an oral medication.
- The newest medications to improve cholesterol are the PCSK-9 inhibitors that block the PCSK-9 enzyme so that the membrane receptors are recycled instead of being destroyed so more and more LDL is removed from the blood into the cell. These medications are very effective at lowering cholesterol and are currently recommended to be used with a statin; but I believe soon, they’ll be FDA-approved to be used alone. They have also been shown to reduce the risk of heart attacks, strokes, and death. There currently are two medications in this class called Praluent (Alirocumab) and Repatha (Evolocumab). These are subcutaneously injected medications and currently, are challenging to get approved by insurance companies as they are EXPENSIVE!
If you need to take a cholesterol-lowering medication; almost always it is something you will need to take for the rest of your life. The only exceptions would be people who have high cholesterol because of poor diet and/or excess calories and then change their lifestyle by eating better and not consuming extra calories or by burning extra calories (i.e. exercise!).
Q. How can I determine my risk of atherosclerosis?
A. Healthcare providers evaluate a person’s history, perform an examination and check laboratory data to help determine a person’s risk. There are five main risk factors (primary risk factors) for atherosclerosis and those are:
- High blood pressure
- High LDL cholesterol
- Smoking tobacco
- Family history
In general, we consider anyone with two or more primary risk factors to be at increased risk of atherosclerosis and thus at increased risk for premature heart attack, death, stroke, etc. There are less serious risk factors like being overweight and not exercising, but these are considered secondary risk factors.
There are also cardiovascular risk calculators available. One can be found at www.cvriskcalculator.com. It calculates a person’s 10-year risk of heart disease and looks solely at age, sex (male or female, not whether you have sex!), race, total cholesterol, HDL, systolic blood pressure, diastolic blood pressure, whether or not you are being treated for hypertension or diabetes, and whether or not you smoke. It does not look at family history. If the risk is less than 5%, the ACC/AHA (American College of Cardiology/American Heart Association) guidelines suggest that a person would not benefit from a statin. However, a Harvard study published by Ankur Pandya in the Journal of The American Medical Association suggests that there would be a benefit from statins if the 10-year risk is 3% or more!
Q. So what does it all mean?
A. Realistically, we are all going to die. We are biological machines that eventually wear out. The optimal life span is about 100 years, plus or minus a few. To optimize our chances of living an optimal life span we can do several things. We cannot change our genetics… yet, but we can manage the effects of our genes – we can treat high cholesterol with medications when lifestyle changes are insufficient; we can treat high blood pressure and diabetes similarly. We can change our lifestyle – we can eat less, eat better and maintain a healthy weight, we can quit smoking, we can exercise.
If you’ve read this far; you are very interested in your health! Congratulations! Talk to us, the providers at Triangle Family Care, if we can answer any more questions you may have or if you think you might need some medication to improve your chances of an optimal life span.