PhytoScience - Article

Cholesterol levels - What numbers should you aim for?

People at high risk of heart disease may need even lower targets for their cholesterol numbers than other adults do.

It's important to keep your cholesterol levels within healthy limits. But if you have other risk factors for developing heart disease, you need to be even more vigilant; especially with your low-density lipoprotein (LDL), or "bad," cholesterol levels.

Types of cholesterol

LDL cholesterol can build up on the inside of artery walls, contributing to artery blockages that can lead to heart attacks. Higher LDL cholesterol levels mean higher risk. High-density lipoprotein (HDL) cholesterol is known as "good" cholesterol because it helps prevent arteries from becoming clogged. Higher HDL cholesterol levels generally mean lower risk.

A blood test to check cholesterol levels {called a lipid panel or lipid profile} typically reports:

  • Total cholesterol
  • HDL cholesterol
  • LDL cholesterol
  • Triglycerides, a type of fat often increased by sweets and alcohol

For the most accurate measurements, don't eat or drink anything (other than water) for nine to 12 hours before the blood sample is taken.

Interpreting the numbers

Cholesterol levels are measured in milligrams (mg) of cholesterol per deciliter (dL) of blood. But what are the optimal levels of these various lipids? Consider these general guidelines.

LDL targets differ

Because LDL cholesterol has a major association with heart disease, it's the main focus of cholesterol-lowering treatment. But it's not as simple as the chart may appear. Your target LDL number can vary, depending on your underlying risk of heart disease.

Most people should aim for an LDL level below 130 mg/dL. If you have other risk factors for heart disease, your target LDL may be below 100 mg/dL. If you're at very high risk of heart disease, you may need to aim for an LDL level below 70 mg/dL.

So who's considered very high risk? You might be if you've had a heart attack or if you have diabetes. In addition, two or more of the following risk factors might also place you in the very high risk group:

  • Smoking
  • High blood pressure
  • Low HDL cholesterol
  • Family history of early onset heart disease
  • Age older than 45 if you're a man, or older than 55 if you're a woman

Canadian Measurements

American units for cholesterol levels are mg/dL while in Canada mmol/L is used. The rough conversion factor is 40. This means that to convert from American to Canadian units you divide by 40. Therefore, 100 mg/dL divided by 40 gives you 2.5 mmol/L.

Lifestyle changes

If your LDL cholesterol is too high, the first thing your doctor will probably suggest is lifestyle changes. Eating more soluble fiber and less saturated fat and cholesterol can improve your cholesterol levels.

Being overweight and inactive tends to increase your LDL cholesterol and lower your HDL cholesterol, exactly the opposite of what you want. Exercise and weight loss can help reverse this trend. This is especially important for people who have large waist measurements {more than 40 inches for men and more than 35 inches for women} because people with this body shape are more likely to develop heart disease.

The best foods to lower your cholesterol and protect your heart

Can a bowl of oatmeal help prevent a heart attack? How about a handful of walnuts, or even your baked potato dressed in sterol-fortified margarine? A few simple tweaks to your diet {like these} may be enough to stave off a cholesterol problem.

Oatmeal and oat bran

Oatmeal contains soluble fiber, which reduces your low-density lipoprotein (LDL), the "bad" cholesterol. Soluble fiber is also found in such foods as kidney beans, brussels sprouts, apples, pears, psyllium, barley and prunes.

Soluble fiber appears to reduce the absorption of cholesterol in your intestines. Gel-like soluble fiber binds bile (which contains cholesterol) and dietary cholesterol so that the body excretes it.

Five to 10 grams of soluble fiber a day decreases LDL cholesterol by about 5 percent. Eating 1.5 cups of cooked oatmeal provides 4.5 grams of fiber; enough to lower your cholesterol. To mix it up a little, try oat bran or cold cereal made with oatmeal or oat bran.

Walnuts, almonds and more

Studies have shown that walnuts can significantly reduce blood cholesterol. Rich in polyunsaturated fatty acids, walnuts also help keep blood vessels healthy and elastic. Almonds appear to have a similar effect, resulting in a marked improvement within just four weeks.

A cholesterol-lowering diet in which 20 percent of the calories come from walnuts may reduce LDL cholesterol by 12 percent. For a 1,200-calorie per day diet, a little less than 1/3 of a cup of walnuts is about 240 calories, or 20 percent of the total calories for the day.

All nuts are high in calories, however, so a handful will suffice. As with any food, good or bad, eating too much can cause weight gain, and being overweight places you at higher risk of heart disease. To avoid gaining weight, replace foods high in saturated fat with nuts. For example, instead of using cheese, luncheon meat or croutons in your salad, add a handful of walnuts or almonds.

Fish and omega-3 fatty acids

Studies in the 1970s showed that Greenland Eskimos had a lower rate of heart disease than did other individuals living in Greenland at the same time. Analysis of dietary differences between the groups showed that the Eskimos ate less saturated fat and more omega-3 fatty acids found in fish and whale and seal meat.

Research since that time has supported the heart-healthy benefits of eating fish. If you can't dine with the Eskimos, other good sources of omega-3 fatty acids include flaxseed, walnuts, canola oil and soybean oil.

Omega-3 fatty acids are noted for their triglyceride-lowering effect, but they also help the heart in other ways such as reducing blood pressure and the risk of blood clots. In people who have already had heart attacks, fish oil {or omega-3 fatty acids} significantly reduces the risk of sudden death.

Doctors recommend eating at least two servings of fish a week. The highest levels of omega-3 fatty acids are in mackerel, lake trout, herring, sardines, albacore tuna and salmon. However, to maintain the heart-healthy benefits of fish, bake or grill it.

Foods fortified with plant sterols or stanols

Foods are now available that have been fortified with sterols or stanols; substances found in plants that help block the absorption of cholesterol.

Margarines and orange juice fortified with plant sterols can help reduce LDL cholesterol by more than 10 percent. The amount of daily plant sterols needed for results is at least 2 grams; which equals about two 8-ounce servings of plant sterol-fortified orange juice a day.

Plant sterols or stanols in fortified foods don't appear to affect levels of triglycerides or of "good" high-density lipoprotein (HDL) cholesterol. Nor do they interfere with the absorption of the fat-soluble vitamins; vitamins A, D, E and K.

However, the American Heart Association recommends foods fortified with plant sterols only for people who actually have high levels of LDL cholesterol.

Soy

Long thought to have cholesterol-lowering effects, a recent meta-analysis by the American Heart Association's Nutrition Committee showed soy protein actually has very little impact on reducing cholesterol levels. In January 2006, the American Heart Association issued a statement saying the cardiovascular health benefits of soy protein are minimal at best. No benefit was seen on HDL, triglycerides, or blood pressure and even with a large intake of soy, only a small impact on LDL was seen.

Though it may not lower your cholesterol, soy does contain vitamins and minerals and is a good source of fiber. It's also a healthy low-fat alternative source of protein.

Cut fats first

The first step for a heart-healthy diet is to reduce your intake of bad fats; especially saturated and trans fats. If cutting out bad fats isn't enough to reduce your cholesterol, you may want to try adding soluble fiber, nuts and fish to your diet. If you need more boost from your foods, try adding foods fortified with plant sterols.

Eating a combination of these cholesterol-lowering foods increases the benefit. But dietary changes alone are not always enough for everyone. If your cholesterol is still high after you've revised your diet and increased your physical activity, your doctor may suggest adding cholesterol-lowering medications to your treatment plan.

Medications may be needed

When lifestyle changes aren't enough to reach your cholesterol targets, your doctor may prescribe medications to help lower your cholesterol. These drugs are not a replacement for lifestyle changes. You'll still need to eat properly and exercise.

Statins: Are these cholesterol-lowering drugs right for you?

Should you be on a statin? These cholesterol-lowering drugs have benefits and risks. Find out whether your risk factors for heart disease make you a good candidate for statin therapy.

Statins, drugs that are used to lower cholesterol, are being touted as one of the wonder drugs of the 21st century. They work by blocking a substance your body needs to make cholesterol. They may also help your body reabsorb cholesterol that has accumulated in plaques on your artery walls, helping prevent further blockage in your blood vessels. Statins include well-known medications such as atorvastatin (Lipitor), simvastatin (Zocor), lovastatin (Mevacor), pravastatin (Pravachol), rosuvastatin (Crestor) and others.

Already shown to be effective in lowering cholesterol, statins may have other potential benefits. But doctors are far from knowing everything about statins. Are they right for everybody with high cholesterol? What happens when you take a statin for decades? Can they help prevent other disease?

Here's some information to help you put information about statins into perspective as you weigh whether they're right for you.

Should I be on a statin?

Whether you need to be on a statin depends on your cholesterol level along with your other risk factors for cardiovascular disease. If you have high cholesterol, meaning your total cholesterol level is 240 milligrams per deciliter, or mg/dL, (6.22 millimoles per liter, or mmol/L) or higher, or your "bad" cholesterol (LDL) level is 130 mg/dL (3.68 mmol/L) or higher, the numbers alone won't tell you or your doctor the whole story.

High cholesterol is only one of a number of risk factors for heart attack and stroke. Before you're prescribed a statin, your cholesterol level is considered along with other factors including:

  • Family history of high cholesterol or cardiovascular disease
  • Lifestyle
  • Blood pressure
  • Age
  • General health
  • Presence of diabetes
  • Excess weight
  • Smoking
  • Peripheral vascular disease; narrowing of the arteries in your neck, arms or legs

If the only risk factor you have is high cholesterol, you may not need medication because your risk of heart attack and stroke is probably already low.

If your doctor decides you should take a statin, you and your doctor will have to decide what dose to take. Statins come in varied doses — from as low as 5 milligrams to as much as 80 milligrams, depending on the medication. If you need to decrease your LDL cholesterol significantly — by 50 percent or more, it's likely you'll be prescribed a higher dose of statins. If your LDL cholesterol isn't as high, you'll likely need a lower dose. Talk to your doctor if you have concerns about the amount of statins you're taking.

Lifestyle is still key for lowering cholesterol

Lifestyle changes are essential for reducing your risk of heart disease, whether you take a statin or not. Quitting smoking, eating a healthy diet, getting daily activity and managing stress are examples of lifestyle changes that will improve cholesterol, and most all of the other risk factors for heart disease. In fact, lifestyle changes may have a greater impact on reducing risk of heart disease and stroke than does medication alone.

If you're following the recommended lifestyle behaviors but your cholesterol {particularly your low-density lipoprotein (LDL), or "bad" cholesterol} remains high, statins might be an option for you. Risk factors for heart disease and stroke are:

  • High cholesterol
  • High blood pressure
  • Diabetes
  • Excess weight
  • Family history of heart disease
  • Physical inactivity
  • Heavy alcohol use
  • Poor stress and anger management
  • Age
  • Smoking
  • Peripheral vascular disease; narrowing of the arteries in your neck, arms or legs

Consider statins a lifelong commitment

You may think that once your cholesterol goes down, you can stop taking medication. But, if your cholesterol levels have decreased as a result of taking a statin, you'll likely need to stay on it indefinitely. If you stop taking it, your cholesterol levels will probably go back up.

The exception may be if you make significant changes to your diet or lose a lot of weight. Substantial lifestyle changes may allow you to maintain low cholesterol without continuing to take the medication, but do so under your doctor's supervision.

The side effects of statins

Although statins are well tolerated by most people, they do have side effects, some of which may go away as your body adjusts to the medication. Side effects include:

  • Muscle and joint aches (most common)
  • Nausea
  • Diarrhea
  • Constipation

There are two potentially serious side effects of statins of which you need to be aware:

  • Liver damage. Occasionally, statin use causes an increase in liver enzymes. If the increase is only mild, you can continue to take the drug. If the increase is severe, you may need to stop taking it, which usually reverses the problem. If left unchecked, increased liver enzymes can lead to permanent liver damage. Certain other cholesterol-lowering drugs, such as gemfibrozil (Lopid) and niacin, increase the risk of liver problems even more in people who take statins. Because liver problems may develop without symptoms, people who take statins have their liver function tested periodically.

  • Muscle problems. Statins may cause muscle pain and tenderness (statin myopathy). The higher the dose of statin you take, the more likely you are to have muscle pains. In severe cases, muscle cells can break down (rhabdomyolysis) and release a protein called myoglobin into the bloodstream. Myoglobin can damage your kidneys. Certain drugs when taken with statins can increase the risk of rhabdomyolysis. These include gemfibrozil, erythromycin (Erythrocin), antifungal medications, nefazodone (Serzone), cyclosporine and niacin. If you take statins and have new muscle aching or tenderness, check with your doctor.

It's important to consider the effects of statins on other organs in your body, especially if you have health problems such as liver or kidney disease. Also, check out whether statins interact with any other prescription or over-the-counter drugs or supplements you take.

Keep in mind that when you begin to take a statin, you'll most likely be on it for the rest of your life. Side effects are often minor, but if you experience them, you may want to talk to your doctor about decreasing your dose or trying a different statin. Don't stop taking a statin without talking to your doctor first.

Are there other options?

Statins effectively reduce bad cholesterol (LDL). But, because of genetic differences, the type or dose of statin each person takes can vary. For example:

  • If you are not able to lower your LDL to the desired goal using statin medication, your doctor may add ezetimibe (Zetia) to your treatment plan or switch to a combination ezetimibe and simvastatin medication (Vytorin). This combination will help drop your LDL level further, perhaps even another 15 percent to 20 percent. You may have heard reports that the combination medication of ezetimibe and simvastatin (together, these two medications are called Vytorin) is no more effective than taking simvastatin by itself. But, this small study didn't find any differences in death, hospitalization or heart attacks between the two medications. If you are on this combination medication, you should continue to take it unless your doctor tells you otherwise.

  • If you have both high LDL and high triglycerides, you may benefit from combining the statin with niacin (Niaspan) or combining the statin with a fibric acid drug such as fenofibrate (TriCor) or gemfibrozil (Lopid). The risk of muscle problems is higher when these medications are paired, so to combat that risk, your dose of statins may be lowered to less than 20 mg.

  • If you have just high triglycerides, use of niacin (Niaspan) is very effective. Fibric acid agents (TriCor and Lopid) are another option. Fish oil (omega-3 fatty acid) supplements (Lovaza) in 2- to 4-gram doses also can help.

  • If your high-density lipoprotein (HDL) cholesterol is low, niacin might be the best choice to raise it. Fibric acids also are useful but less effective than niacin. Exercise and weight loss may help, as well.

In some cases, one medication may simply not be effective and a different drug must be substituted. For other people, lifestyle changes may be all that are needed to lower cholesterol.

What else can statins do?

High cholesterol affects all arteries, not just those in the heart. Its negative effects permeate the body, so it's likely that the benefits of lowering cholesterol might have widespread health benefits as well.

One promising benefit of statins appears to be their anti-inflammatory properties, which help stabilize the lining of blood vessels. This has potentially far-reaching effects, from the brain and heart, to blood vessels and organs throughout the body.

In the heart, stabilizing the blood vessel linings would make plaques less likely to rupture, thereby reducing the chance of a heart attack. Statins also help relax blood vessels, lowering blood pressure. In addition, statins have blood-thinning effects, reducing the risk of blood clots. For these reasons, doctors are now beginning to prescribe statins before and after coronary artery bypass surgery or angioplasty, and following certain types of strokes.

Other benefits of statins could include:

  • Prevention of arthritis and bone fractures. Statins might help protect against osteoporosis, arthritis and bone fractures, but more research is needed to confirm this benefit.

  • Prevention of cancer. It's unclear whether statins might reduce your cancer risk. While some studies have suggested statins could reduce cancer risk, later studies haven't found a connection between statin use and reducing risk for breast, colon, prostate, respiratory, skin, or gastrointestinal cancers.

  • Reduction in the risk of dementia and Alzheimer's disease. Statins might help keep your brain healthy, but more research is needed.

  • Protection of the kidneys. Statins may help protect kidneys, through their effects on cholesterol and blood pressure and perhaps their ability to reduce inflammation.

Statins may also be helpful in controlling the body's immune system response after an organ transplant.

Weighing the risks and benefits of statins

When thinking about whether you should take statins for high cholesterol, ask yourself these questions:

  • Do I have other risk factors for cardiovascular disease?
  • Am I willing and able to make lifestyle changes to improve my health?
  • Am I concerned about taking a pill everyday, perhaps for the rest of my life?
  • Am I concerned about statins' side effects or interactions with other drugs?

It's important to take into account not only your medical reasons for a decision, but also your personal values and concerns. Talk to your doctor about your total risk of cardiovascular disease and discuss how your lifestyle and preferences play a role in your decision about taking medication for high cholesterol.

A hidden disorder

High cholesterol has no symptoms, but your genetic makeup {reflected in family history of high cholesterol or heart disease} might make you more prone to the condition, even if you eat right and exercise. That's why it's so important to have your cholesterol checked at least once every five years. Finding the problem early allows you to take action before it's too late.