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New cholesterol-lowering guidelines to help borderline patients

Category: Family Fare
Date: 6/26/01

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Texas

The middle-aged woman was a little concerned.

A recent checkup showed her cholesterol count had gone above 200--206, in fact--for the first time in her life. She did not eat that much saturated fat; she loved donuts but indulged only rarely; she quit smoking and did not drink; and she had been getting more exercise. What could have happened?

The doctor said not to worry. Her cholesterol count was "borderline" and needed to be watched. If it was still above 200 next checkup, well, then they would discuss possibilities, but for now, do not worry. It was not that much above the magic number of 200.

But in just a matter of days the National Cholesterol Education Program (NCEP) of the National Institute of Health (NIH) issued new guidelines recommending even people with borderline cholesterol counts could benefit by taking cholesterol-lowering medications and sticking to more restricted diet.

Now what? What does all this mean?

According to Dr. Mary "Mickey" K. Bielamowicz, professor and Extension nutrition specialist at Texas A&M University, it means people who are not able to adjust their cholesterol levels through diet and exercise alone will have a new tool to use to improve their health. Bielamowicz includes Nutrition Education for Medical Conditions as one of her areas of expertise.

The guidelines, which were published in the May 16 issue of the Journal of the American Medical Association, recommended total acceptable cholesterol levels remain at 200, and that a total of less than 100 mg/dL is optimal for LDL-cholesterol (low-density lipoprotein, or "bad" cholesterol); 130 to 159 mg, borderline; 160 mg, high; and 190 mg, very high.

The guidelines also listed HDL ("good" cholesterol) levels are too low if they are less than 40 mg.

According to the National Heart, Lung and Blood Institute (NHLBI) of the National Institutes of Health (NIH), too much fat in the diet can lead to too much LDL cholesterol in the blood. This "bad" cholesterol can build up on the inside walls of arteries, causing restricted blood flow and leading to heart disease, as well as stroke and other vascular diseases.

HDL cholesterol is called "good" because it protects against heart disease, so higher numbers are preferred for HDL, Bielamowicz said. Less than 40 mg/dL of HDL can increase risk for heart disease. HDL levels of 60 or more are preferred, she added.

The strategy behind the new guidelines is this: Since high blood cholesterol levels have been linked to heart disease and strokes, lowering blood cholesterol will help prevent these and other serious medical conditions.

Even people with slightly-elevated cholesterol levels may find themselves with prescriptions for cholesterol-lowering medications. In fact, the NIH has estimated, if these guidelines are followed across the country, the number of people who are prescribed these drugs could almost triple--from 13 million to about 36 million.

Some experts believe these new guidelines could help lower rates of heart disease by as much as 40%.

"I believe previous research as well as future research by NIH and other clinical trials are conducted, that the research findings will be indicative of the need to help those who are not able, through exercise or diet or weight reduction and/or obesity prevention, to control their lipids," Bielamowicz said. For some people, she said, "ordinary lifestyle changes, which work for many," might not be enough.

"Saturated fat (in the diet from both animal products and vegetable products such as tropical oils) seems to increase cholesterol (in the blood) more than eating cholesterol itself," she added. Dietary cholesterol can be found in egg yolks, meats and "anything that has a mother. In other words, it has to be an animal product to have cholesterol."

Lowering cholesterol levels in the blood is very important for reducing cardiovascular risk, said Dr. Nancy Dickey, board certified family physician and interim dean at the College of Medicine, Texas A&M University System Health Sciences Center.

But people with borderline high cholesterol levels probably will not--and more important, probably should not--get prescriptions for cholesterol-lowering medications the first time their levels go above 200, she said. Much more information is needed before the medications are prescribed.

Conventional methods of reducing cholesterol are still the first line of defense.

"I think what we really have to continue to do is motivate people and empower them to begin exercising if they are not doing it, eat healthfully with ... more complex carbohydrates, less starch, sodium, sugar and fat, as well as moderate amounts of protein," Bielamowicz said. "Stress reduction and exercise are both important. I have doctor's orders to do that daily."

While some cholesterol is necessary for good health--it helps in the formation of cell membranes, some hormones and other tissues in the body--too much can be harmful.

Bielamowicz said cholesterol levels are affected by many things, some which can be controlled and some which cannot. Those which can be controlled include:

--Diet: Reducing the intake of foods containing saturated fat and cholesterol can help lower cholesterol levels;

--Weight: Maintaining a healthy weight can also be a factor in lowering cholesterol;

--Exercise: At least 30 minutes of physical activity a day can also help.

Some of the things that cannot be controlled are:

--Age and gender: Cholesterol levels tend to rise with age. Also, women tend to have higher cholesterol levels after menopause;

--Heredity: Cholesterol levels, like eye and hair color, tend to run in families. Genetic heritage can at least partially determine cholesterol levels.

While some believe the new guidelines will benefit some people who are having trouble reducing their cholesterol levels through conventional methods, others are concerned about the wisdom of that many new prescriptions for a borderline condition and the safety of cholesterol-reducing medications themselves.

Dickey explained several factors must be taken into consideration before the prescriptions are written. "It depends a lot on an individual's risk factor," she said. For instance, does the patient have high blood pressure, diabetes, a family history of heart disease? Does the patient smoke? Have more conventional methods of reducing cholesterol levels been honestly tried? Has the patient "been honest in giving a shot at lifestyle modifications?" Dickey asked. Some people, she added, might even ask for prescriptions for cholesterol-lowering medications because they do not want to bother with changing their diet and exercise. The guidelines do not work that way, she said.

The medications themselves come with their own risk factors, Dickey said, and patients need to know what those risks are. Some cholesterol-lowering medications can damage liver function; some can cause vomiting, indigestion and/or diarrhea; some can cause heart problems; some can have serious or even dangerous interactions with other medications.

"We've got this whole list of medications," for helping lower blood cholesterol levels, Dickey said. Before prescribing any of them, "we have to look at each one for the drug interactions or adverse reactions."

Patients must tell their doctors what other medications they are taking--their lives could depend on it.

Cholesterol-lowering drugs come with a high price, she said, which is only partially their actual financial cost, so these drugs are not prescribed lightly.

Dickey advised patients who are borderline and concerned to remember that 200 is "statistical normal." That means within every individual is a range of normal that can be influenced by many factors.

"There is some range of 'normal' for each individual. That means the difference between 200 and 206 may be extraordinarily small," she said. "It may even be within the error range of the machine doing the measuring.

"So patients may need a couple of readings to assure that they are really above normal and not just below or at normal. If the numbers are creeping up or are routinely above--even just above--normal, lifestyle changes and possibly medication are needed. But a single minimal elevation may be lab error, failure to be fasting or an early sign of a problem."

So follow your doctor's advice; use changes in diet and exercise as the first line of defense against higher blood cholesterol levels; and if medication becomes necessary, learn what choices are available and what their costs/risks are.

And take comfort in the fact that maintaining good health is a world-wide effort.

"We need to be thankful that food scientists and processors, meat scientists and others who have worked for years to try to change the amount of fat and the quality of fat in foods," Bielamowicz said. "The products are more healthful" without as much saturated fat.

High Plains Journal