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High Cholesterol

Beating high cholesterol

Over the past few decades, doctors and scientists have come to understand high cholesterol (hypercholesterolemia) as a major health issue and identified it as a major underlying cause of heart disease.

High cholesterol is generally defined as a blood cholesterol level of 240 milligrams per deciliter (mg/dL) or higher. It can result from dietary and lifestyle habits, diseases that affect the endocrine organs, or your genetic makeup. Even though a person with high cholesterol levels may have no symptoms, over time the condition can lead to serious medical problems, including heart attacks and stroke.

Fortunately, through the education efforts of physicians and researchers, Americans have begun to take better care of their bodies, adopting healthy diets and exercising regularly. Effective new drugs are available to treat this condition, and deaths related to high cholesterol have decreased in the past three decades. High cholesterol can now be effectively treated.

Synonyms

• • Hyperlipidemia
  • Hypercholesterolemia
  • Hyperlipoproteinemia

Detailed Description

To understand high cholesterol, it helps to know a little bit about what happens in your body. Cholesterol and fatty acids, in the form of triglycerides, are transported through your bloodstream wrapped in proteins. This combination molecule makes up a lipoprotein, of which there are several varieties with specific tasks in the body. Major lipoproteins include the following:

• • Chylomicrons: large particles that transport dietary fat and cholesterol to muscles (for energy), to fat tissue (for storage), and to breasts (for milk production).
  • Very low-density lipoproteins (VLDL): particles synthesized by the liver that deliver triglycerides to muscles (for energy) and to fat tissue (for storage). As the triglycerides are removed from these VLDL particles, they collect cholesterol; the majority become converted to LDL particles.
  • Low-density lipoproteins (LDL): particles that carry about 70% of the blood's cholesterol. They are small enough to cross the blood vessel walls and enter tissue. LDL can be harmed by oxidation, a natural process that nevertheless can damage blood vessel walls. For this reason, LDL is known as the "bad cholesterol."
  • High-density lipoproteins (HDL): are transported out of the intestines and liver in quantities greater than the body's tissue can use, so the excess is returned to the liver for elimination in bile or to be remade into VLDL. HDL is crucial for this reverse transport of cholesterol, which is why it is nicknamed the "good cholesterol."" High HDL is associated with a lowered risk of coronary artery disease.

A high level of LDL in the bloodstream corresponds to a high level of cholesterol. LDL tends to deposit its cholesterol on artery walls. These deposits, known as plaques, harden the arterial wall and obstruct blood flow. When arteries become so congested that tissues begin to lose their blood supply, the condition is called atherosclerosis, a serious, progressive condition that can lead to heart attack, stroke, and gangrene of the extremities. LDL has been justly nicknamed "bad cholesterol."

HDL has been called "good cholesterol" because it transports cholesterol to the liver, where it is broken down and removed from the blood stream. High levels of HDL are associated with lower levels of cholesterol and lower chances of heart attack and stroke.

How Common Is High Cholesterol?

High cholesterol is a common health risk in the United States. The American Heart Association estimates that 98.1 million American adults (51.9%) have total blood cholesterol values of 200 mg/dL and higher, and about 39.4 million American adults (about 20%) have levels of 240 or higher.

Symptoms

High cholesterol itself has no symptoms. You can have elevated blood cholesterol levels for many years and not know it, which in turn can lead to a silent buildup of plaque within the arteries. However, symptoms may occur as a result of atherosclerosis, a common consequence of continuous high cholesterol levels. The following are symptoms of serious diseases related to atherosclerosis. If you experience any of these symptoms, contact your physician immediately:

• • Chest pain (angina)
  • Dull pain in the buttock, calf muscle, or thigh during physical exercise or exertion
  • Sharp pains in the legs or feet when you are at rest
  • Tingling or numbness in an armor leg, partial vision, or speech loss

Conditions That May Be Mistaken for High Cholesterol

High cholesterol is high cholesterol, whether it is caused by poor dietary choices, genetic predisposition, or the effects of drugs or disease.

How Is High Cholesterol Diagnosed?

All it takes is a blood test to find out what your cholesterol levels are. Unless you're in a high-risk group (if you smoke, eat a high-fat diet, are under excessive stress, or have certain chronic illnesses such as diabetes and thyroid or liver dysfunction), testing once every five years is fine. Men over 45 and women over 55 should be tested yearly. People on cholesterol-reducing regimens or medications will require more frequent checks to ensure their cholesterol levels and liver enzymes are within safe limits. The blood for the test is usually drawn after a night of fasting to ensure accuracy.

Your doctor is primarily interested in three values:

• • Total blood (serum) cholesterol: This is the overall amount of cholesterol in your bloodstream. A person with total cholesterol greater than 240 milligrams per deciliter (mg/dL) has more than twice the risk of heart disease compared to someone whose cholesterol is 200 mg/dL. Here are the National Cholesterol Education Program guidelines:
    • Desirable: less than or equal to 200 mg/dL
    • Borderline: 200 to 240 mg/dL
    • High: greater than 240 mg/dL
  • HDL: The higher your HDL ("good" cholesterol) level, the better. According to the National Cholesterol Education Program, your HDL should be 35 mg/dL or higher. An HDL level less than 35 mg/dL increases your risk for heart disease.
  • LDL: LDL ("bad" cholesterol) is a better predictor of heart disease risk than your total blood cholesterol. If your LDL level is high or borderline and you have other risk factors for heart disease, your doctor will likely plan a treatment program for you. Here are the National Cholesterol Education Program guidelines:
    • Desirable: less than 130 mg/dL
    • Borderline: 130 to 159 mg/dL
    • High: 160 mg/dL and above

Goals of Treatment

High cholesterol is a treatable condition. Dietary changes and exercise are often successful in bringing moderately elevated cholesterol levels back to desirable levels. If you are at high risk, your doctor may prescribe a cholesterol-lowering drug in addition to diet and exercise. Proper treatment can even help reduce atherosclerotic plaque buildup to some extent. The goals of treatment -- to prevent the worsening of atherosclerosis and reduce the risk of heart attack and stroke -- can be effectively accomplished.

Treatment Overview

Many at-risk people never need to take prescription medications to lower their cholesterol levels. Simply making some informed choices may be all you need to restore your circulatory system to its former glory:

• • Eat a healthy diet low in saturated fat and cholesterol, and aim to include five to six servings of fruits and vegetables. The American Heart Association recommends you limit your daily intake of cholesterol to 300 mg on a prevention program (what the AHA calls Step I), 200 mg per day on a reversal regimen (what the AHA calls Step II). In addition, no more than 30% of your daily caloric intake should be from fats, and no more than 10% of that should be from saturated fats. Every 1% drop in overall cholesterol reduces your chances of dying of cardiovascular disease by 2%.
  • If you drink, do so moderately. Although moderate use of alcohol seems to increase HDL levels, the damage alcohol can do to your liver could compromise the LDL receptors' ability to filter out the bad cholesterol. Stick to no more than one glass for women, two glasses for men, per day.
  • Toss the cigarettes. If you smoke, stop. Smoking does so much damage to the cardiovascular system that it practically rolls out the red carpet for atherosclerosis. Cigarettes are also linked with increased LDL and decreased HDL. Smokers will gain immediate benefits from quitting and should see significant decreases in LDL and total cholesterol.
  • Get moving. One of the biggest favors you can do for your bloodstream is get up off the couch and exercise. You don't have to train like a marathon runner; half an hour of brisk walking a few times a week will boost your HDL levels almost immediately and lower your LDL. The more you do, the better you will feel, and the healthier your cardiovascular system will become.

For some people, diet and exercise aren't enough to bring down dangerous cholesterol levels. They may need to take prescription medications to reduce or even halt the production of cholesterol in the liver. All cholesterol-lowering medications should be taken only with the advice of and under the supervision of your physician.

Drug Therapy

Four types of medications are available for the treatment of high cholesterol: HMG-CoA reductase inhibitors, bile acid sequestrants, nicotinic acid, and fibric acid derivatives. The class of drug your physician prescribes will depend on a variety of factors, including your HDL and LDL levels and your family medical history, age, and gender.

• • HMG-CoA reductase inhibitors: This is a new class of drug that has demonstrated significant effectiveness in lowering cholesterol levels. Drugs in this class are probably the most frequently prescribed for high cholesterol, but they do have side effects, including muscle aches and pains, joint pain, and gastrointestinal upset. These drugs can cause increases in liver enzymes, although they rarely cause liver damage. This class of drug has also been associated with decreased cholesterol production and increased LDL receptors in the liver.
    
    Classified as statins, numerous HMG-CoA reductase drugs are available for prescription and include Mevacor (lovastatin), Baycol (cerivastatin), Pravachol (pravastatin), Lescol (fluvastatin), Zocor (simvastatin), and Lipitor (atorvastatin). Although these drugs carry an increased risk of side effects, these reactions are considerably less dangerous than allowing your cholesterol to rise to dangerous levels.
  • Bile acid sequestrants: These are drugs that convert more of the cholesterol in the bloodstream into bile acids, which are more easily eliminated from the body. These drugs can also increase the number of LDL receptors in the liver. Side effects of this class of drug can include bloating, diarrhea, constipation, and elevated triglyceride levels. The most commonly prescribed drugs in this class include Colestid (colestipol hydrochloride) and LoCholest or Questran (cholestyramine). You should have periodic cholesterol and bleeding time function tests while on this type of medication to make sure it is working well and to monitor any side effects.
  • Nicotinic acid: This is another word for niacin, or vitamin B-3, and is commonly used to lower cholesterol by decreasing VLDL (very low density lipoproteins). Nicontinic acid can reduce total and LDL cholesterol and triglycerides while raising HDL cholesterol. As with other classes of cholesterol-lowering drugs, this drug requires liver-enzyme monitoring to guard against liver damage. The most common side effects include gastrointestinal upset, skin flushing, and elevations in glucose, uric acid, and liver enzymes. Symptoms of flushing, itching, and headache caused by dilation of blood vessels are especially troublesome. These symptoms can be eased by taking an aspirin 30 minutes beforehand, or taking B-3 with food.
  • Fibric acid derivatives: These drugs inhibit cholesterol production in the liver and lower VLDL levels. They are primarily effective in lowering triglycerides, but also increase HDL. Although these drugs are well tolerated by most patients and two large studies have demonstrated their effectiveness, the drugs' use has declined in the United States after a large World Health Organization study failed to prove their effectiveness. Some patients who take these drugs have gastrointestinal problems; they may cause a higher incidence of gallstones.

Monitoring the Condition

Your doctor will want to keep close tabs on your condition if you have high cholesterol levels. Monitoring often involves periodic laboratory tests to measure total blood cholesterol, LDL, and HDL levels, as well as liver-enzyme monitoring if you are taking some types of cholesterol-lowering drugs. Based on the laboratory findings, your doctor may recommend or adjust cholesterol-lowering medications as well as exercise and diet.

Complications

The most serious complications that can result from high cholesterol are those associated with atherosclerosis:

• • Coronary artery disease
  • Angina pectoris and unstable angina
  • Congestive heart failure
  • Heart attack
  • Stroke/transient ischemic attack (TIA)
  • Gangrene
  • Blood clots and arterial obstruction

Quality of Life

High cholesterol itself doesn't affect your quality of life, but the diseases that can result from it can. It is never too late to seek the assistance of a physician in heading off the dangers of high cholesterol. Lowering your cholesterol means making some changes in the way you live, but most people aren't facing anything too radical -- mainly just some dietary adjustments and exercise. You're in charge, and many lifestyle choices you make directly affect your cholesterol levels for the better, some virtually right away.

Considerations for Women

Estrogen has been shown to have beneficial effects on HDL and LDL levels. As a woman enters menopause, the ovaries stop producing estrogen, putting women at risk of atherosclerotic disease. Menopausal and postmenopausal women may benefit from estrogen replacement therapy. Ask your doctor if this choice is right for you.

Considerations for Older People

Men age 45 and older and women age 55 and older have a higher incidence of high cholesterol and should be screened annually.

Considerations for Children & Adolescents

High cholesterol is not reserved for the middle-aged and self-indulgent. Too many young adults, teens, and even children have plaque deposits on their arteries. Atherosclerosis, for instance, can begin in childhood and progress without symptoms for years. Almost all of these cases is a direct result of a poor diet overloaded with fats. But like their meat-and-cheese-loving elders, young people can control much of the problem with a little common sense, better fitness, and a lot more leafy vegetables.

Supplements

• • Fish oil: An alternative to eating salmon is to take capsules of fish oil or flaxseed oil, both of which contain omega-3 fatty acids. The recommended dose of fish oil is four to six standard capsules per day. With flaxseed oil, take one tablespoon per day.
  • Niacin: Before today's cholesterol drugs were developed, the main treatment for high cholesterol was large doses of vitamin B-3, or niacin. It still works. In a study at the Oregon Health Sciences University in Portland, researchers gave 136 people with high cholesterol either niacin (1.5 g a day) or lovastatin (20 mg a day). Both treatments produced very similar results.
    
    However, the cholesterol-lowering dose for niacin equals anywhere from 250 mg to 1,800 mg a day. The problem is that at such high doses, niacin causes "flushing," a sudden, uncomfortable feeling of heat similar to a menopausal hot flash. As a result, many people who try niacin stop using it. You can minimize flushing by starting with a low dose and increasing it slowly over time under a doctor's supervision.
  • Vitamin E: If you have high cholesterol, you're at risk for heart disease. Many studies show that vitamin E helps prevent heart attack. Most experts recommend 400 IU to 8000 IU per day.

Herbs

• • Garlic: Dozens of studies have demonstrated that garlic lowers cholesterol. For example, at the New York Medical College in Valhalla, a team led by Stephen Warshafsky, M.D., analyzed five very rigorous studies and determined that consuming one clove of garlic per day decreased total cholesterol by about 9%.
  • Psyllium: Never heard of psyllium (pronounced silly-um)? It's the main ingredient in Metamucil, the bulk-forming laxative. Like oat bran, psyllium is rich in soluble fiber that helps lower cholesterol. At the University of Kentucky in Lexington, researchers studied 248 people whose average initial cholesterol level was 229 mg/dL. Everyone at ate a low-fat, low-cholesterol diet. In addition, some took 5 g of psyllium fiber (about a tablespoon of Metamucil) twice a day. Six months later, average cholesterol in the diet-only group fell 4%, but in the diet-psyllium group, it dropped 10%. If you use psyllium, take it with plenty of water or juice.

Self-Care Measures

Self treatment is key in preventing the harmful effects of high cholesterol. Through a sensible program of low-fat diet, exercise, weight loss, and smoking cessation, you can effectively manage high cholesterol.

• • If you smoke, quit. Smoking is a major risk factor for heart disease. Smokers account for approximately 70% of all people with atherosclerosis. This association is even stronger in people with diabetes and high blood pressure. Smoking has also been associated with a two- to four-fold increased risk of coronary heart disease, a greater than 70% increase in death from coronary heart disease, and an elevated risk of sudden death. These risks are compounded in the presence of high cholesterol levels.
  • Don't drink to excess. Women should limit themselves to one drink a day; men, two. (A drink equals 12 ounces of beer, one shot of spirits, or five ounces of wine -- a standard wine glass about half full.) Red wine may be the smartest choice, as recent studies have shown that its abundant antioxidants may help lower cholesterol levels.
  • Exercise regularly. Any regular exercise helps reduce cholesterol -- and it doesn't even have to be strenuous. At the Cooper Institute for Aerobics Research in Dallas, researchers compared the effects of brisk walking and non-vigorous strolling on cholesterol in 102 women who had not been exercisers. Both forms of walking delivered similar cholesterol reductions.

Your Diet

• • Eat less saturated fat. In one study, Oxford University epidemiologist Robert Clarke, M.D., analyzed 395 studies on diet and cholesterol. His conclusion: if you replace 60% of the saturated (animal) fat in your diet with polyunsaturated (vegetable) fat, and eliminate 60% of dietary cholesterol (by limiting animal foods), total cholesterol declines 10% to 15%.
    
    The foods most likely to raise cholesterol are meats and whole-milk dairy products. They are high in both fat and cholesterol. Fried foods are also high in fat. Steer clear of margarine, which contains trans-fatty acids that raise cholesterol almost as much as butter does. Substitute olive oil for butter and margarine.
  • Eat more salmon and other cold-water fish. They contain omega-3 fatty acids, a special type of fat that helps reduce cholesterol and risk of heart disease.
  • Eat more high-fiber foods. Perhaps you already know that oat bran helps reduce cholesterol. In fact, oat bran is just one of many high-fiber foods that do this. Others include barley, fruits, vegetables, beans, and grains.
  • Eat more soy foods. According to University of Kentucky researchers, people with moderately high cholesterol (200 mg/dL to 240 mg/dL) can reduce their levels by about 9% by eating two ounces of soy protein -- the kind found in tofu -- each day.
  • Start your day right. Breakfast is the easiest meal to alter to help lower cholesterol. Forget the bacon and eggs; instead, eat a whole-grain cereal or bread with some fruit. According to the National Health and Nutrition Examination Survey II, Americans with the lowest cholesterol generally report eating a whole-grain item for breakfast.
  • Snack on fruits or vegetables instead of high-fat foods.

Websites & Organizations

American Heart Association
7320 Greenville Ave.
Dallas, TX 75231
Phone: 214-750-5300

Agency for Health Care Policy and Research (AHCPR)

Cardiac Health Web

Heart Health

Heart Information Network

Heartline
9500 Euclid Ave., Room EE-37
Cleveland, OH 44195
Phone: (800) 478-4255

Heartlink

Heartmates, Inc.
PO Box 16202
Minneapolis, MN 55416
Phone: 800-9HM-3331 (800-946-3331)
Email: heartmates@outtech.com

Mayo Clinic

MedPed and Inherited High Cholesterol
University of Utah
410 Chipeta Way, Room 167
Salt Lake City, Utah 84108
Phone: 888-244-2465
Fax: 801-581-6862

National Heart, Lung, and Blood Institute, Information Office
P.O. Box 30105
Bethesda, MD 20892-0105
Phone: 301-251-1222

New York Online Access to Health

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