Blood Fats: too much of a good thing

Cholesterol is a lipid. Lipid is another name for fat, which is an essential component for the healthy functioning of plants and animals. Cholesterol is an essential lipid for our bodies. It is used in cell membrane maintenance. It is a precursor to Vitamin D, which is made in the skin as a result of sun light exposure. It is the precursor to many of the hormones of our body including the sex hormones, (estrogen, progesterone and testosterone), and adrenal hormones such as cortisol. Cholesterol is so important that our bodies do not rely on cholesterol from food sources alone. We actually manufacture about two-thirds of the cholesterol that we use in the liver. The cholesterol is derived from other fats in our bodies. These fats are either ingested or manufactured. Saturated fat stimulates cholesterol production and over-production. Excessive calorie intake resulting in over weight can also stimulate excessive cholesterol production.

Cholesterol is in the shape of a ring. Triglycerides, the other major fat in the body is in the shape of a chain. These fats are transported in the blood by lipoproteins. These are sphere shaped bodies that consist of the fat, (which is not water soluble), and protein, (which is water soluble). It is the water solubility of the lipoprotein structure that allows for transport in the blood. The lipoproteins are categorized according to size. Chylomicrons are the largest in size and the lowest in density. There are also very low density lipoproteins, (VLDL), low-density lipoproteins, (LDL), and high-density lipoproteins, (HDL). There are other lipid and non-lipid molecules that are significant in the development of arteriosclerosis. These include lipoprotein (a), apolipoprotien B, homocysteine, and fibrinogen.

Low Density Lipoprotein, (LDL), plays a major role in atherosclerosis, (the process by which our arteries age and become occluded). LDL in is not inherently dangerous. It transports about 75% of the cholesterol to the body’s cells. Remember, cholesterol is an important building block for our hormones and cell membranes. If LDL becomes oxidized, however, it can produce inflammation in the lining of our arteries. This results in atherosclerosis. Oxidation is another normal process in our body. However, when it becomes imbalanced it can produce an excess of reactive molecules that cause inflammation. This triggers white blood cells to gather at the site of inflammation. They form a fatty substance called plaque; the first step in atherosclerosis. As plaque builds up, the arterial wall becomes stiff and narrowed and blood flow is restricted. It is this process that can ultimately lead to heart attack and stroke. Factors that can cause an increase in oxidation and subsequent inflammation include, excessively high cholesterol and LDL cholesterol levels, stress, poisons, (tobacco, heavy metals), allergen, (including food sensitivities), infections, hormonal imbalances such as hypothyroidism and metabolic abnormalities such as diabetes. It is desirable to keep cholesterol and LDL as low as possible and minimize oxidative stress in our bodies. The size of the LDL particle is an important factor in the promotion of arteriosclerosis. Small Dense LDL particles are associated with an increased risk to arteriosclerosis. Larger LDL particles are not as likely to promote arteriosclerosis. This is a relatively new concept and its ultimate relevance in the promotion of arteriosclerosis is being debated in the medical literature.

High Density Lipoprotein, (HDL), is important in preventing atherosclerosis. HDL helps to remove excess cholesterol from the walls of the arteries and return it to the liver. Levels above 45 are considered protective. Levels below 35 are associated with an increased risk to heart attack and stroke.

Triglycerides are chain type fats where cholesterol is a ring type fat. Triglycerides are important building blocks for the cell membrane and other specialized fats. High levels are considered dangerous. They are associated with an increased risk of atherosclerosis, stroke and diabetes. It is desirable to keep triglyceride levels below 150.

Guidelines:

LDL Cholesterol is the primary target of therapy. There are numerous studies in the medical literature that support the idea that high levels of LDL Cholesterol are related to an increased risk in Coronary Artery Disease, Stroke and other chronic degenerative diseases of aging.

LDL Cholesterol

70 values less than 70 are advised for people with a previous heart attack or stroke or other evidence of significant narrowing of the arteries.
100 values of 100 or less are considered optimal
100-130 these are acceptable values in people with no other risk factors
130-159 these are excessive values and efforts to lower them should be undertaken with diet and non prescriptions supplements
160-189 these are high levels and should be treated with diet non-prescription supplements and prescription medication
>190 these are dangerous levels and should be treated with diet, non-prescription supplements and prescription medications.

Total Cholesterol

<200 values less than 200 are considered optimal
200-239 values in this range are borderline high and efforts to lower cholesterol via diet and non-prescription supplements is recommended
>240 values in this range are high and efforts to lower cholesterol with diet, non-prescription supplements and prescription medications is recommended

HDL Cholesterol

<40 values in this range are considered undesirable and efforts to raise HDL are recommended


Major Risk Factors that Modify LDL Goals:
Cigarette Smoking
Hypertension (characterized by a systolic BP greater than 135 and or a diastolic BP greater than 85
Low HDL Cholesterol (less than 40)
Family history of premature CHD
Age (men > 45; women>55)
Insulin Resistance and or Diabetes

From an Anti-Aging Medicine view point, the lower the cholesterol and LDL and the higher the HDL the better. Simply stated, you would like your cholesterol, LDL and HDL to look like the best values of a younger person.

Consequences of high Cholesterol, high LDL, high Triglycerides and Low HDL:

Coronary Heart Disease is still the leading cause of death in the United States. Half of the patients with Coronary Heart Disease have high cholesterol and LDL as an important contributing factor. Every time a person’s cholesterol level drops by a point the risk of heart attack drops by 2%. The younger a person is when first diagnosed with high cholesterol the more significant high cholesterol is to their risk of heart disease. Other factors are also important; smoking, high blood pressure, insulin resistance, diabetes and stress. 40% of people with high cholesterol do not develop serious heart problems. This simple fact speaks to the complexity of assessing risk and the need to individualize a risk reduction program.

Stroke risk factors are similar to those for Coronary Heart Disease

Insulin Resistance is a phenomenon whereby a person makes an adequate amount of insulin but they are not as sensitive to the insulin message as they should be. It has been observed that a high level of triglyceride and low HDL is associated with insulin resistance. Other factors that promote Insulin Resistance are hereditary factors and diet. While it is generally observed that Insulin Resistance is common in overweight individuals, it is actually quite common in thin people as well. The lipid we observe are caused by the underlying problem of insulin resistance. When we do routine blood screening and we see this pattern of lipid abnormality we can suspect insulin resistance. This will guide therapy in terms of diet and supplements that improve insulin resistance.

The Effect of Age and Sex on Cholesterol Levels

More than half of adults have a total cholesterol over 200. 20% have levels greater than 240. This is due to our diet. In other cultures, where dietary fat is low and dietary fiber is high cholesterol levels are much lower. In general cholesterol levels are lower when we are younger and increase when we are adults. Sex differences are notable in that HDL is higher in menstruating women than in men. This difference decreases after menopause. The significance of high cholesterol in healthy elderly is no longer a matter of debate. Recent scientific studies suggest high levels of cholesterol and LDL should be treated.

Strategies for lowering Cholesterol, LDL and Triglycerides

The Role of Lifestyle Modification

Modest lowering of cholesterol, LDL and Triglycerides will produce a substantial reduction in risk to arteriosclerosis, heart disease, (heart attack), cerebrovascular disease, and Alzheimers Disease. Lifestyle modification is the first step as it is often adequate to achieve the desired results.

Diet

A diet that consists of 20-30% fat, 20-30% protein and 50-70% carbohydrate will lower cholesterol and LDL by 10-15%. The variations are dependent on the individual. Why can some people do an “Atkins” type diet, which is very high in fat and lower their cholesterol? Not only do they lower their cholesterol but they lose weight and feel well. Still others do well on a “Dean Ornish” type diet. This is a very restricted fat diet. Some people thrive on it. They lower their cholesterol and feel great. I believe that we have different dietary needs and these needs must be individualized for a person to experience benefit without feeling deprived. One size does not fit all. Perhaps those that do well on the Atkins type diet have underlying insulin resistance and must minimize intake of the starchy carbohydrates to optimize their metabolic profiles. The South Beach Diet is a healthier version of the Atkins Diet and one that is considered safe for most people.

Some dietary recommendations have value regardless of your individual needs. In general refined foods are not desirable. The first broad categories of refined foods are those with refined sugar in them. Candy, dairy deserts, pastries, soft drinks, sugar added to coffee or tea constitutes the main sub categories. The second broad category is foods high in refined carbohydrate. These include bread, rice, pasta, and potatoes. Other highly processed foods in this category include pretzels, potato chips, corn chips and party mixes. This does not mean you should not eat any bread, rice, pasta or potatoes. It means that they should not be the staple of your diet. Rather they should be eaten more like a condiment; in smaller portions. When you do eat these foods make sure they are unrefined, (brown rice, whole grain bread, baked potato) or appropriately cooked, (al dente pasta). More importantly; limit the portion size. The third broad category of foods to minimize or avoid are those high in saturated fats. Red meats, fried foods and most processed foods fall in to this category. If you are going to eat red meat look for organic free-range meat. Avoid red meat from feed lot fed animals. Some fats provide health benefits when used in moderation. The monounsaturated fat from olive oil is one. The polyunsaturated fats from deep sea fish, nuts and seed are another.

So what should you emphasize in your diet? Again, it should be individualized. Generally speaking you want to emphasize unprocessed foods such as whole grains, organic fruits, vegetables, nuts and seeds. If you are going to eat fish look for deep sea fish such as wild salmon, tuna, and halibut. If you are going to eat poultry or meat look for organically raised, free range products.

Modest calorie restriction to achieve a healthy weight is desirable. Excess weight may interfere with the benefit from some class of medications used to lower cholesterol, (the statin drugs such as Crestor, Lipitor, Pravachol and Zocor)

What we drink matters also

Adequate hydration is an important, simple and inexpensive way to optimize our health. One study noted that men who drank 5 or more glasses of water per day had half the heart attack and stroke incidence of men who drank two or less glasses of water per day.

Alcohol, in moderation may raise HDL cholesterol. Unfortunately, it is almost impossible to lose weight and drink alcohol. Pregnant women and those at risk for alcohol abuse should not drink alcohol.

Drug Therapies for Lowering Cholesterol

Statin Drugs

HMG CoA reductase inhibitors are often referred to as statin drugs. They inhibit a key enzyme that controls the rate of cholesterol production. They also may increase the ability of the liver to remove LDL cholesterol from the body. Recently evidence is accumulating that this family of drugs exhibits anti oxidant properties that protect from heart disease and stroke. This family of drugs has been show to interfere with the production of Coenzyme Q 10. This is an important metabolic intermediary and antioxidant. I recommend that patients taking statins supplement with 60 mgs of CoQ10 two times per day. CoQ10 should be taken with meals to enhance its absorption.
Some patients experience muscle aches and fatigue when using statins, making continuous use problematic. When taking this class of drugs I recommend that liver function tests be checked at 4-6 month intervals. This class of drugs can lower cholesterol by 10-50%.

Fibric Acid Derivatives

Fibrates are another class of medication used to lower cholesterol. They are typically used when Triglycerides are the primary lipid that is elevated while cholesterol is the secondary one. Fibrates can increase HDL as well. Gemfibrozil, (Lopid), and fenofibrate, (Tricor) are the two medications used in this category. Side effects include muscle aching, sun sensitivity, skin rash and gastrointestinal disturbance. This class of drugs can interact with other medications such as statin drugs, coumadin, some antibiotics, some diabetes medications and grapefruit juice. This class of drugs can lower cholesterol/LDL by 10-20%.

Zetia

Zetia is a new agent that lowers cholesterol and LDL by inhibiting absorption of cholesterol by the intestines. It can be used alone or in combination with a statin drug to help a person achieve an optimal Cholesterol and LDL. It seems to be very safe with a low side effect profile. Given alone it can lower cholesterol/LDL by about 10%. When taken with a statin it can lower cholesterol/LDL by as much as 50%

An Integrated Approach

I am always looking for ways of helping patients achieve an optimal lipid profile. This means achieving safe levels of cholesterol, LDL and Triglycerides, maximizing HDL and protecting from LDL cholesterol oxidation.

I am not against prescription drugs to help patients accomplish their goal. The problem is that the individual often uses the medicine and makes no other changes in diet, exercise patterns or stress reduction. Nevertheless, I do not hesitate to prescribe medications to lower cholesterol while encouraging patients to modify lifestyle and use supplements that decrease the potential side effects of prescription drugs or improve their benefit.

Complimentary and Alternative Medicine Strategies:

DIET: Diets low in saturated fat, (animal products), low in sugar, and high in fiber are the key. Unprocessed foods are important, (See our diet information section). What is the point of taking supplements or even drugs if you are going to injure yourself by eating poorly?

EXERCISE: You do not have to run marathons. Regular long slow distance activities are the key. Activity is the key! Gardening, walking, cycling, swimming are all good activities. You can do short amounts of activity throughout the day. Won’t it be interesting when the hard-to-find parking spaces are the furthest away? Twenty to sixty minutes of cumulative activity per day is desirable, (remember, it does not have to be done all at one time).

CURCUMIN: We know curcumin as a spice called tumeric. Curcumin has been shown to lower cholesterol, LDL, and triglycerides. In addition, it can raise HDL. The recommended dose is 500 mgs two times per day. Curcumin may be beneficial in preventing the oxidation of LDL. Oxidized LDL is believed to aggravate the atherosclerotic process. Curcumin can be useful in patients with arthritis because of its anti-inflammatory properties.

FIBER: Water-soluble fiber helps the body to remove bile acids from the intestinal tract. Since bile is made from cholesterol the body uses cholesterol to make more bile. The result is a lowering of Cholesterol and LDL. I often suggest a fiber supplement in addition to a high fiber diet in patients who have elevated cholesterol and LDL cholesterol and chronic gastrointestinal problems such as Irritable Bowel Syndrome, Constipation and Hemorrhoids. When using a fiber supplement it is important to drink enough water each day, (60-80 ounces per day).

GARLIC: Garlic has been shown to effectively lower serum cholesterol and triglycerides. In addition it can inhibit platelet aggregation. This means that it makes your blood less sticky. It can also increase fibrinolysis. This is another mechanism for decreasing blood stickiness. A therapeutic dose can be obtained from chewing one clove of garlic daily. For those adverse to the taste or odor a supplement with 5,000 micrograms of allicin daily is recommended. Garlic may have the additional benefit of helping to optimize blood pressure.

GINGER: Ginger is a spice from the same family as curcumin. It has many beneficial properties. It has been shown to lower cholesterol and LDL. In animal models it has been shown to prevent arteriosclerosis. One to two capsules of a ginger extract twice daily can be helpful. Ginger can also be useful in patients with gastrointestinal problems such as gastro-esophageal reflux, nausea and irritable bowel syndrome.

GREEN TEA: Green tea has been shown to lower Cholesterol, LDL and Triglycerides. It may also raise HDL. In addition, green tea has potent antioxidants that inhibit LDL oxidation. I recommend green tea as a beverage for those who can tolerate caffeine. One can also use a supplement of green tea extract in a dose of one to three capsules daily.

GUGULIPID: Gugulipid is made from the resin of the commiphora mukul tree of India. Gugulipid has been part of traditional Indian medicine for centuries. Gugulipid has been shown to reduce Cholesterol and LDL while raising HDL. The therapeutic dosage of Gugulipid is based on guggulsterone content. The recommended dose is 25 mg of guggulsterones three times per day. You must read the label to make sure you are getting the appropriate dose of guggulsterones. This product is not reliably effective in lowering cholesterol and LDL. I no longer recommend it.

NIACIN: Niacin is a cross over nutritional product. In low doses it is a vitamin. In high doses it is a medication that lowers cholesterol, LDL, triglyceride and lipoprotein (a), while raising HDL. The dose of niacin, (not niacinamide), which has this therapeutic effect is 1000-3000 mgs per day. There is prescription niacin that is slow release. For many people this is effective. There is an over the counter niacin known as “no flush niacin”, (inositol hexanicotinate).This product has not proven effective and I do not recommend it. There is a prescription form of niacin sold as “Niaspan” which is effective. Since our body manufactures most cholesterol at night I encourage my patients to take the dose at bedtime. Regular niacin can cause severe flushing which many patients find undesirable. This can be avoided by taking aspirin, with food, 1 hour before taking the niacin. Infrequently, niacin in high doses can raise liver enzymes. I recommend checking the Lipid Profile and Liver Enzymes at four to six month intervals. Niacin has been shown to decrease fibrinogen. Elevated fibrinogen levels are a mark of underlying inflammation and another risk factor for heart attack. Niacin has also been shown to optimize the size of LDL cholesterol so that it is less atherogenic. It should be used under the direction of a physician.

PANTOHINE: is a derivative of Pantothenic Acid. It has been shown to lower Cholesterol and LDL cholesterol and raise HDL cholesterol. The recommended dose is 250 mgs two three times per day with meals. It can lower cholesterol/LDL by 5-10%.

POLICOSANOL: Policosanol is a derivative of sugar that has been shown to lower total cholesterol and LDL cholesterol while raising HDL. It is available over the counter. The recommended dose is 20 mgs taken in the evening with dinner. To date there have been no reports of adverse effects or drug interactions. Policosanol can lower cholesterol/LDL by 5-10%. I check the cholesterol/LDL after 3 months of use to see if it is effective.

PHYTOSTEROLS: Phytosterols are plant-based molecules found in grains, nuts, seeds and vegetable oils. They have been shown to lower cholesterol by inhibiting absorption of dietary cholesterol. Phytosterols have been shown to improve immune function. They have also been shown to improve prostate and colon health. The recommended dose is two capsules three times per day with meals. This is a product with multiple health benefits. It may help optimize immune function and minimize the adverse effects of hormones in the body. I use a product called Cholestepure in a dose of 2 capsules three times per day with meals.

RED YEAST RICE EXTRACT: This is a product used in Traditional Chinese Medicine. It has been found to have cholesterol-lowering properties. When analyzed it actually has statin like drugs in it. Lovastatin or Mevacor is present in small doses. I do not recommend this supplement. If you are going to take a statin, take it in a form where the quality control is good; i.e. a prescription medication.

TEAFLAVIN: Teaflavin is a concentrated extract of green tea. It has been shown to produce a 10% reduction in cholesterol and LDL cholesterol in a double blind study. It is safe and effective for those who need mild to moderate reduction in cholesterol and LDL.

VITAMINS: A good “anti-oxidant” vitamin and mineral supplement will help prevent oxidation of LDL and thus reduce the harm it can do. I recommend a product called SEVAK taken in a dose of 2 capsules twice daily with breakfast and dinner.

Policosanol and Teaflavin seem to be effective for individuals who require modest lowering of cholesterol (10% or less) and who would like to avoid prescription medications.

Niacin can be effective but is difficult to take for some.

Each person must create a unique program to optimize the blood fats. This is based on factors from the individuals’ history, family history, life style factors, and lab data. It is more important to optimize the lipid profile than to adhere to a dogma: “I only want to do it naturally”. Working with a knowledgeable practitioner is very helpful. The adverse effect of certain prescription medication may be offset by appropriate supplementation. The non-prescription products may have adverse effects. There is no one size fits all solution. The most important issues:
1. A diet appropriate to the individuals’ unique metabolism, food tolerances, and life style.
2. An exercise program that allows the individual to achieve 1,200 to 1,600 calories of aerobic energy expenditure per week.
3. The willingness to work at creating and maintaining the attributes of a meaningful life.

Remember; “Perfection is the Enemy of Good.” Trying to be perfect does more harm than good, in most cases.