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The New Cholesterol Challenge

On the day after new recommendations on cholesterol levels made front-page news, a few fitness buffs were working out at the Downtown Athletic Club on their lunch hour. An informal sampling showed that they knew a lot about exercise and a healthy diet, but were a little shakier when it came to their blood-cholesterol levels.

Harry Altscher, 57, a lawyer who lives in Ellicott City, stopped for a minute to towel off the sweat and admit that he didn't know what his LDL, or harmful cholesterol, is. This is the figure that some researchers now believe can't be too low for a healthy heart.

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But Altscher isn't sure. "I'm not fully convinced cholesterol does as much damage as they say if you have the right lifestyle," he said. "I'm just not a pill person. Maybe I'll load up on oat bran." Besides, he added, 20 years later new reports always seem to come out that contradict the old research.

Richard Baker, 44, a waiter, was leaning on an exercise machine nearby. He has one of the significant risk factors for cardiovascular disease -- his father died of a heart attack at a relatively early age. Still, when Baker, who lives in Cedarcroft, went to his doctor recently, all he learned was that his total cholesterol was 203 and his HDL (the good cholesterol) was high.

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Gerald Popko, 50, was doing bicep curls with a slow, rhythmic motion while he explained he's already on the cholesterol-lowering drug Lipitor. He was the only one who knew his LDL: 120 milligrams per deciliter.

"My doctor told me it's the lowest he's ever seen," said the Roland Park hairdresser.

We have bad news for you, Gerald. And Harry and Richard.

Under the new recommendations, endorsed by the National Institutes of Health and the American Heart Association, patients at high risk of heart attack or stroke should get their LDL under 70 -- a number difficult to reach without using large doses of cholesterol-lowering drugs. In government guidelines published just a couple of years ago, the figure was 100. That's now the goal for those at moderately high risk, which was previously 130.

Panelists criticized

Backing up these new recommendations, published July 13 in the journal Circulation, are data from five major clinical trials of statins, the most commonly used cholesterol-lowering drugs. From the beginning, the findings were controversial. Some experts worried that the importance of lifestyle changes in preventing cardiovascular disease would get lost in the emphasis on drugs. About 7 million more Americans could find themselves on statins, already the most prescribed medicines in the United States.

Much of the funding for the clinical trials came from the very companies that make these drugs, but researchers say that did not influence the results. More worrisome to some consumer groups, most of the heart disease experts on the panel that wrote the new recommendations received consulting or speaking fees or other support from manufacturers of statins.

So what does this mean for you?

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Maybe not much. Not every doctor is planning to put more of his or her patients on higher doses of drugs -- yet. Dr. Roger Blumenthal, director of the Johns Hopkins Ciccarone Preventive Cardiology Center, thinks that getting patients' LDL levels below 100 is "still a reasonable clinical strategy." He still feels lifestyle factors such as diet and exercise are the "cornerstone."

But if nothing else, the recommendations are further evidence that lowering your level of harmful cholesterol is a good idea, whether you are at high risk or low risk for cardiovascular disease. After all, for a third of the people who have a heart attack, their first symptom is their last. In other words, they're dead.

But what price a low LDL? Statins are expensive drugs. If you don't have a prescription plan, you could spend around $100 a month. (Of course, no one's arguing that having a heart attack isn't costly.)

Dr. James Richardson at Union Memorial Hospital treats elderly patients who often don't have drug insurance. They tell him, "as long as you can give me samples, I can take it."

"I am concerned patients will resist upping the dosage," he said. His patients also sometimes stop taking statins -- without telling him -- because the drugs can cause muscle pain in their arms and legs. These are people who have arthritis anyway. "Studies have shown that it's one thing to hand patients a prescription, another to get them to fill it."

Elmer Stump, 68, a Timonium project manager, falls in the "very high risk" category because he had a heart attack a decade ago. When he was told the new recommended goal for people like him was under 70, he sounded stunned. "Oh, my god. Everyone who has high cholesterol says there's no way you can get it below 100."

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Stump's LDL is 166 -- on medication. Although cholesterol-lowering drugs are considered very safe, he experienced muscle aches and "senior moment" episodes while taking statins. His cardiologist switched him to the drug Zetia, which works by reducing the amount of cholesterol that your body absorbs.

Stronger treatment

One reason people don't know their LDL is that many doctors give patients their total cholesterol, a meaningless number if you don't know your LDL (which should be low) and HDL (which should be high). A decade ago, you were considered healthy if that total was under 300; the recommendation has since been lowered to 200. Expect the focus to change so you'll be hearing about your bad cholesterol ad nauseum, especially if you have risk factors such as being overweight, a smoker or diabetic. While your triglyceride and HDL numbers may turn out to be just as important, that's not where the research is being done.

But the biggest change that could result from the new recommendations is that millions more people will be urged to start taking cholesterol-lowering drugs -- perhaps you.

"This is the beginning of a more aggressive treatment program," said Dr. Stephen Pollock, chief of cardiology and director of the Heart Institute at St. Joseph Medical Center in Towson. "We've just added a whole new group of people [who should be taking statins]."

Pollock started prescribing larger doses of cholesterol-lowering drugs to his patients six months ago, when the results of the PROVE-IT study (one of the five clinical trials) first came out. "Pretty much all patients have to be reassessed," he said.

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Pollock is on Lipitor himself. He had gotten his LDL down to 90 on the standard dose, but after the PROVE-IT results came out, his cardiologist increased it from 10 to 40 milligrams. Pollock's LDL dropped to 68.

With all the hoopla surrounding these new recommendations, the focus has been on a goal that's hard to reach without taking drugs. But the Circulation article states that "Therapeutic lifestyle changes (TLC) remain an essential modality in clinical management." That means losing weight, not smoking, eating the right diet and exercising regularly are just as important as medication. It's boring, perhaps, but better than popping pills for the rest of your life.

Saturated fat a target

Katherine Tallmadge, national spokeswoman for the American Dietetic Association and a consultant in private practice in Washington, believes that people can lower their LDL drastically by diet alone -- but not if they want to continue to eat the traditional American diet. She calls saturated fats (found in those yummy steaks, butter, chocolate and snack foods) the "evildoers of the diet."

"People come in here with sky-high cholesterol levels," Tallmadge said of her private practice. By having them reduce their saturated fat intake to 4 percent of their daily calories, "then their [harmful] cholesterol plummets. When you see people's numbers change dramatically over just a few months, you become a believer."

It almost goes without saying that most people are going to have trouble limiting their saturated fat to 4 percent. (That's very low. The American Heart Association recommends no more than 8 to 10 percent of calories from saturated fat daily.) For someone eating 2,000 calories a day, 4 percent would be about 8 grams of saturated fat. A tablespoon of butter has 7 grams. And don't even think about eating a Big Mac (11 grams).

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Saturated fat has become an even bigger bugaboo than dietary cholesterol, but your intake of the latter should still be less than 300 milligrams a day. (An egg has about 200 milligrams.) It won't hurt to cut your salt consumption to below 2,300 milligrams a day either -- a little over a teaspoon.

Most doctors still see lifestyle changes as the most important defense against cardiovascular disease. If you focus on a heart-healthy diet, keep your weight down, don't smoke and exercise 30 minutes a day most days, you've made a good start.

"I think we have to set more reasonable goals for people," said Dr. Taylor Cymet, section head of family medicine at Sinai Hospital. "It's hard to encourage a patient with no symptoms and who feels fine to take medication. You have to put it in the context of the person."

Lowering your LDL by diet

American Dietetic Association spokeswoman Katherine Tallmadge says she has lowered her patients' harmful cholesterol levels drastically by having them:

* Limit their consumption of saturated fat to 4 percent of the calories they eat.

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* Increase their intake of soluble fiber (which binds with fatty acids), found in oats and oat bran, barley, and legumes (beans and peas).

* Eat 1 to 2 ounces of nuts daily.

* Get omega-3 fatty acids (from fatty fish like salmon and sardines.)

* Have 5 to 9 servings of deeply colored fruits and vegetables daily.

Most important, she believes, is limiting bad fats. Here is her list of common foods with their calories and saturated fat content. Remember that 4 percent of a 2,000-calorie diet would be around 8 grams.

Calories / Grams saturated fat

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Butter, 1 tbsp. -- 102 / 7

Corn oil, 1 tbsp. -- 120 / 2

Olive oil, 1 tbsp. -- 119 / 2

Canola oil, 1 tbsp. -- 124 / 1

English walnuts, 1/4 cup --185 / 2

Prime rib, 1 oz. -- 110 / 11

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Lean roast beef, 1 oz. -- 47 / 2

Skinless chicken breast, 1 oz. -- 48 / 0.3

Wild coho salmon, 1 oz. -- 39 / 0.3

Flounder, 1 oz. -- 33 / 0.1

Cheese, 1 oz. -- 100 / 6

Reduced fat cheese, 1 oz. -- 70 / 3

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Whole milk, 1 cup -- 150 / 5

1 percent milk, 1 cup -- 102 / 1.5

Skim milk, 1 cup -- 86 / 0

Chocolate, 1 oz. -- 135 / 5

Coconut milk, 1 cup -- 452 / 51

Cholesterol terms

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A recent nationwide survey by Harris Interactive of people who reported having high cholesterol found that the majority (77 percent) didn't know the two sources of cholesterol.* Only 27 percent knew that their LDL should be below 100 mg / dL. To help bridge the cholesterol awareness gap, here are some important terms:

Cholesterol. A fat-like substance in the blood and cells of the body that helps form cell membranes, hormones and bile acids.

HDL. High-density lipoprotein cholesterol, the good kind that helps carry LDL cholesterol back to the liver for removal. The higher your levels, the better.

LDL. Low-density lipoprotein cholesterol, the harmful kind that can build up on artery walls, forming plaque and causing them to narrow.

Saturated fat. The mostly animal-based fat that causes our bodies to make too much cholesterol.

Statins. Drugs that interfere with the liver's manufacture of cholesterol. They are used to treat high LDL.

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Triglycerides. Another type of blood fat that can block blood vessels. Elevated levels are bad.

*The majority of cholesterol is produced naturally in the liver. Certain animal-based foods contribute cholesterol directly.


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