All About Cholesterol
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All About Cholesterol

Don't know your HDL from your LDL? Our experts explain why understanding what your numbers mean could save your life.

The Cholesterol Lowdown

As the health director of Ladies' Home Journal, I know a thing or two about cholesterol. But I was a little surprised by the response when our editor-in-chief, Sally Lee, took an informal poll during a recent staff meeting. "How many of you know your cholesterol numbers?" she asked the roomful of mostly women. About a third of the hands went up. Then I jumped in and asked, "How many of you really understand what those numbers mean or how to change them?" Every hand went down.

So, if a bunch of research-oriented journalists don't know what to do with all their data, we thought, how can we expect our readers to know? We asked our LHJ Facebook fans the same questions and they posted answers such as this one: "I never really understood the numbers and how they work. I just eat my Cheerios." In fact, only about 21 percent of women 18 to 44 know their total cholesterol level, according to a 2007 survey by the Society for Women's Health Research. And just under 14 percent know their LDL ("bad") cholesterol level, while only 12 percent know their HDL ("good") cholesterol number. That backs up a previous Harris Interactive survey, which found that 81 percent of women 50 and older don't know their LDL or HDL numbers -- and nearly a quarter of those respondents had actually suffered a heart attack or stroke or had diabetes.

Most doctors don't have time to sit down with you and explain your lab results in detail, so many women never learn the true extent of their risk for heart disease, or how to prevent it. Heart disease is still the number one killer of men and women, and women are less likely than men to have their cholesterol levels under control, according to a large analysis of managed-care and Medicare plans.

We realized it was time to get back to basics. So we consulted two top experts from our LHJ Medical Advisory Board: Michael F. Roizen, MD, chief wellness officer at the Cleveland Clinic, and cardiologist Holly S. Andersen, MD, director of education and outreach at the Ronald O. Perelman Heart Institute at New York City's New York-Presbyterian Hospital, to fill in the blanks.

Total Cholesterol

What's ideal: Under 200

First, cholesterol isn't technically the same thing as fat. Cholesterol is a soft, waxy, fatlike substance mainly produced by the liver. And it's not inherently bad; in fact, it's vital to all kinds of bodily processes, from keeping cells healthy to making hormones. But sometimes the body cranks out more cholesterol than you need, and the things you eat, what you weigh, and the way you live can add even more, putting you at risk for heart disease. But improving your diet, losing weight, and increasing your exercise can reduce those risks, so keep reading.

We've learned a lot about cholesterol in the past 20 years, says Dr. Andersen, and what we know is constantly evolving, too. "When I was in medical school, for example, we were taught that having a total cholesterol number of less than 250 was normal, and we didn't even know what HDL and LDL were. Today I still look at total cholesterol, and we know we want it to be under 200, but HDL and LDL are much more important."

The Bad Guy: LDL

What's ideal: Under 100

It stands for low-density lipoprotein, but you can just remember the "L" stands for "lousy," says Dr. Roizen. LDL circulates through your bloodstream and deposits cholesterol in the walls of your blood vessels. This actually starts when you're young; you get little deposits of the fatty stuff here and there. Over the years it can build up, and other stuff traveling through your bloodstream, such as waste products or calcium, gets stuck on there, too. All this gunk combines to form plaque, which can cause blockages, chest pain, shortness of breath, or a heart attack (see "How Plaque Can Become a Heart Attack" on the next page). To prevent plaque, you generally want to get your LDL as low as it can go.

What Moves the Needle

If you're overweight, the most important thing you can do to reduce your LDL is lose weight, says Dr. Roizen. You should especially focus on your waistline. "The fat around your belly releases proteins and hormones that can make your LDL higher and raise your blood pressure and your risk of diabetes," says Dr. Andersen. That means cutting the simple-carb calories that go right to your belly -- sugary stuff like sodas, candy, cakes, white breads, rice, and pasta.

Processed foods containing trans fats are harmful, too. Fish oils and plant fats tend to be okay. If you're not overweight and don't have a big waist but your LDL is still high, then you need to try lowering your intake of meat and dairy products, too, says Dr. Andersen. It can be tough to eat an almost vegan diet, she says, but those who do it really see a dramatic reduction in their LDL. Working out more is also effective. When lifestyle efforts don't reduce your LDL enough, your doctor will probably suggest that you go on statin drugs (see "Who Should Take Statins?" on the next page).

The Good Guy: HDL

What's ideal: Over 50

HDL, or high-density lipoprotein, can actually take some of the LDL from your plaque and return it to your liver, where it's processed and disposed of, says Dr. Roizen. Not only does HDL help prevent new gunk from accumulating in your arteries, it can reduce what's there. Women tend to have higher HDL than men do. But the benefits of a high HDL level don't cancel out the bad effects of a high LDL level, says Dr. Andersen. You have to work on improving both numbers to really make a difference in your heart health.

What Moves the Needle

HDL is much more difficult to manipulate than LDL, but experts agree that aerobic exercise is key. "It can take a lot of physical activity, like running a few miles a day, to really bring up your HDL level," Dr. Andersen says. "But any amount of physical activity can improve the quality of your HDL, so that it works better."

"We don't have really good data on this yet," says Dr. Roizen. "But it appears that a little more intense aerobic exercise is much better than a lot of milder exercise. You need to raise your heart rate, but whether you get there from doing cardio or from intense weight training that gets your heart rate up doesn't seem to matter."

Taking niacin (vitamin B3) supplements has also been shown to increase HDL and decrease the risk of stroke and heart attack. Dr. Andersen suggests that you talk to your doctor first to determine the right dose. One side effect to watch for: Niacin can make you flush. Taking it at night may help; so can taking a baby aspirin or 325-mg adult dose aspirin 30 minutes before taking the niacin. Aspirin also has anti-inflammatory effects that can help your heart, but it can cause bleeding problems, so ask your doctor before you take it.

As for food, omega-3s, which are in walnuts, fish oil and algal DHA supplements, can raise HDL, says Dr. Roizen. A moderate amount of alcohol may raise your HDL, too. "I don't tell women who don't drink to start drinking, but one drink a day or maybe two has been shown to improve cardiovascular health in women and improve their HDL," says Dr. Andersen. But alcohol can also increase your risk of breast cancer, so you have to factor in your family history and other risks.

More Crucial Info

The Scoop on Triglycerides

What's ideal: Below 100

Triglycerides are the third part of the cholesterol equation. They are basically fats -- from foods you've eaten or made by the liver -- carried through the bloodstream to be stored in your tissues. A high level increases your risk of coronary artery disease and diabetes. While some guidelines say 150 is normal, Dr. Roizen says that's too high and you should aim for under 100. "Too often 'normal' means heart disease," he says. The triglycerides number really reflects what you've been eating lately. To get the most accurate reading, eat as you normally do in the week or so before you get your cholesterol tested. Don't cut out lots of fat in an attempt to fool the test, because it won't help you assess your real risks. Dr. Andersen says your level also has a genetic component, and sometimes very thin, seemingly healthy women can have a very high triglyceride level.

What Moves the Needle

Triglycerides respond very strongly to dietary changes, says Dr. Roizen. Reducing those simple carbs that quickly turn to sugar (and hit your waistline) is most helpful. Cutting animal fat and increasing exercise can help, too. Although moderate alcohol intake can help raise your HDL, which is good, it will also raise your triglycerides, which is bad. If your triglycerides are high, Dr. Andersen says reducing your alcohol consumption is important.

What's this ratio I'm hearing about?

Lab results may include a ratio that's calculated by dividing your HDL level into your total cholesterol number. If you have a total cholesterol of 200 and an HDL of 50, that's 200/50, or a ratio of 4:1. While many guidelines say the ideal ratio is 3.5:1, Dr. Roizen says an optimal number is unknown and may be more like 2:1. Assessing your actual numbers is more important, according to the American Heart Association. Dr. Andersen says that although people are talking about their ratio now, most experts have moved past it. "I never look at ratio anymore," she says. If you have a high enough HDL you can get a deceptively good ratio. Say you have an HDL of 65, which is good, and a total level of 235. Your ratio would be an acceptable 2.6:1, yet you could still have an LDL of 158 or 170, which is too high. "I wouldn't ignore those LDL numbers," says Dr. Andersen. "You want your LDL as low as possible."

How Plaque Can Become a Heart Attack

At first plaque looks like chicken fat, says Dr. Andersen. As it grows it can obstruct blood flow and cause patients to say things like, "Every time I walk up the stairs now I get chest pain." Worse, as the blood is pounding over this fatty plaque, the plaque can get inflamed and then rupture, which causes a blood clot to form in an attempt to heal the rupture. The clot can then grow or break away and cause a blockage and thus the need for angioplasty (where a balloon is inflated via a catheter to widen the blocked artery), stents (a metal mesh tube that is inserted after the blocked artery is opened by angioplasty), or bypass surgery (where a vein from the leg or other part of the body is surgically routed around the blockage). If the blockage totally stops blood flow to your heart (as in the image, left), you'll have a heart attack -- even if you've never had symptoms before. Dr. Andersen says a 49-year-old patient of hers who was a marathon runner had a heart attack from just the tiniest bit of fatty plaque. "We can't predict when plaque is going to rupture. Sometimes the first symptom of heart disease is death, and that's why we have to practice prevention."

Who Should Take Statins?

Many women can improve their numbers and decrease their risk of heart attack with exercise, weight loss, and eating right. But sometimes willpower is not enough, or despite your best efforts, your stubborn genetics keep your numbers in the red zone. That's when your doctor might suggest you go on a statin. These drugs inhibit an enzyme that controls cholesterol production in the liver. Most statins can lower your LDL significantly and certain ones may raise HDL, too. Statins also have an anti-inflammatory effect that may be as important as their effects on cholesterol for preventing heart disease.

Still, women are less likely to take statins than men, despite being just as much at risk, said a 2008 study from Rush University Medical Center. "In general in this country, we underestimate the risks in women and don't treat them as aggressively as we should," says Dr. Andersen. "And once a woman is diagnosed with heart disease, she is more likely to die from it than a man is." Deaths due to heart disease are continuing to increase in young women, which makes prevention more important than ever. "These are lifesaving drugs that are extraordinarily safe," she says. "I know there's a lot of mistrust about prescription drugs, but these medicines have been used successfully for decades and we've found that women on statins are living longer, with fewer strokes and heart attacks."

Marnie Nussbaum, MD

Marnie Nussbaum, M.D.

Age: 29

Chief resident in dermatology, New York-Presbyterian/Weill Cornell Hospital, New York City

Her numbers:

In 2008

Total: 231

LDL: 149

HDL: 58

TRIG: 121

In 2010

Total: 179

LDL: 95

HDL: 64

TRIG: 101

Her risks: Her mom has high cholesterol and is being treated with statins. Dr. Nussbaum has never been overweight but leads a stressful life. During her busy years in medical school she lived on candy and french fries and "never went to the gym, ever -- I know, I'm a doctor and that's terrible! Then my husband and I were ordering Chinese food or pizza every night."

Her wake-up call: Her blood test in 2008 showed her HDL was pretty good at 58, but her LDL and her total cholesterol were high. "I thought it was my family history and there was nothing I could do about it," she says.

Her action plan: She went to cardiologist Holly Andersen, MD, who insisted that Dr. Nussbaum eat a healthier diet and start exercising. "I told my husband, and he became the enforcer," she says. While he would run, she'd walk and sometimes jog along with him. Although she felt intimidated at first, she started taking a strength-training class. Instead of the greasy takeout foods the couple usually ordered, they began cooking on weeknights and ordering in only every couple of weeks. While her weight didn't change, Dr. Nussbaum's efforts brought her numbers back to healthy levels.

Her challenges: "I used to eat candy throughout the day. I still love it, but now I just have a 'fun size' or two." She cut down on her french-fry intake, and she only allows herself to have the chocolate-chip banana pancakes she loves every two weeks. "I was shocked at what a difference all the changes made," she says.

KC Maurer

KC Maurer

Age: 48

Chief financial officer, the Andy Warhol Foundation for the Visual Arts, New York City

Her numbers:

In 2003

Total: 238

LDL: 157

HDL: 49

TRIG: 188

In 2006

Total: 187

LDL: 78

HDL: 64

TRIG: 80

In 2010

Total: 168

LDL: 93

HDL: 63

TRIG: 58

Her risks: "I've always been fat," Maurer says, and at her heaviest she weighed 330 pounds. She has a family history of obesity and heart disease; her mom had a heart attack at 68. When she was first measured in 2003, Maurer's LDL and triglycerides were high; her protective HDL could have been higher but wasn't bad. While she ate a relatively healthy diet, she says she was a "comfort eater" who had trouble with portion control.

Her wake-up call: On Memorial Day, 2003, Maurer was alone at her beach house in New Jersey, when she suddenly felt dizzy, nauseous, and had some sharp but short-lived chest pain. She also felt short of breath while lying down. She thought she had food poisoning, but she was actually having a heart attack -- her very first symptom of heart disease. Luckily she got to a hospital, although the doctors there dismissed her symptoms until a blood test confirmed the heart attack.

Her action plan: "I went to Dr. Andersen, and she read me the riot act." Maurer started walking, changed her eating habits, and began taking the statin Lipitor. She lost 110 pounds and jogged/walked to the finish line of the New York City Marathon in 2006, 2007, and 2008. "She improved her numbers and greatly reduced her future risk," says Dr. Andersen.

Her challenges: Maurer tore her Achilles tendon in the 2008 marathon and recuperating has slowed her down. She's unhappy that she's gained back some of the weight she lost but is determined to get back on track this year. "I want her LDL closer to or below 70," says Dr. Andersen.

Originally published in Ladies' Home Journal, February 2011.

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