MEDICAL TREATMENT OF HIGH CHOLESTEROL
High cholesterol is present in a high % of American adults. Lowering the LDL cholesterol has been proven in many studies to greatly cut the incidence of illnesses caused by atherosclerosis,such as heart attacks, some strokes, and peripheral artery disease. It does this by preventing the formation, progression, and even causing regression, of atherosclerosis. The goal should be an LDL cholesterol of less than 100 mg.,and in diabetics and those that have already have atherosclerosis, a better goal is less than 75 mg.
Statins inhibit the formation of cholesterol, and are the most effective drugs in lowering cholesterol. They also lower triglycerides somewhat. Frequently companies claim superiority of their product, but all statins are effective and generally well tolerated. The main side effects are well known. Less than 1 person out of 200 develops muscle soreness and weakness, which is reversed quickly with stopping the medicine. Rarely when the medication is continued in spite of these warning signs, more serious side effects occur. Probably everyone has heard that statins can affect the liver. Less than 2% of people taking higher doses of statins develop elevated liver enzymes, which also is quickly reversed by stopping the medicine. It’s recommended that liver enzymes be rechecked after 3 months of treatment, and yearly after; however in practice most doctors test more frequently. Statins that are available now are Mevacor (Lovastatin), Lipitor, Lescol, Pravachol, Crestor, and Zocor (Simvastatin). The dose of various statins varies.
Fibric Acid Derivatives (Lopid and Tricor) lower triglycerides usually 25% to 50%. Triglycerides are a different fat in the blood that is also a risk factor for atherosclerosis and is frequently treated at levels over 300 mg. High triglycerides are especially more common in diabetes. Adverse effects are rare. Lopid, although less expensive than Tricor, can rarely cause gallstones. Both of these drugs have shown a reduction in heart attacks in those that have elevated triglycerides.
Niacin (nicotinic acid) has a favorable effect on LDL cholesterol, triglycerides, and increases HDL cholesterol (the good cholesterol) as much as 35%. Niacin can cause skin flushing and itching, which is a very annoying side effect that keeps it from being used more often. Extended release niacin and taking an aspirin or Advil before a dose sometimes reduces the side effects. In my experience in practice, niacin is a difficult drug to take because of the flushing.
Zetia prevents the absorption of cholesterol that we eat in our diet. A combination of Zetia and Simastatin (Zocor) is available as Vytorin. It lowers LDL cholesterol up to 65%, and is often very effective when people are resistant to a statin alone.
Before statins were available in 1987, resins like Questran, Colestid , and Welchol were used These drugs bind bile acids in the intestine, and increase clearance of cholesterol from the blood. They can lower LDL cholesterol by 20%. Severe constipation is a side effect that prevents more widespread use.
Fish oil (omega-3’s) can decrease triglycerides up to 50%, and have many other beneficial effects. It is available over the counter, or in the form of Lovaza. Patients often buy fish oil capsules and take 1 or 2 a day; they are underdosing. 2 to 4.8 grams of omega 3’s is considered a therapeutic dose. If you take fish oil, discuss the dose with your doctor.
The combination of long acting niacin and lovastatin (Mevacor) is available as Advicor.
Statins are the drugs of first choice for most people with a problem of elevated cholesterol. They can decrease coronary events and deaths, and are a major reason why the incidence of heart attacks has gone down in the United States over the past few decades. Several of the statins are on the generic drug lists of Walmart, Target, Walgreens, and Wegmans; so they are very affordable.
THE NON-DRUG TREATMENT OF HIGH CHOLESTEROL
The non-drug treatments of elevated cholesterol are many. Virtually all newborns are born with a blood cholesterol of less than 150 mg, and it is a “rich diet” in combination with genetics that elevates the values as we get older.
Loss of excess weight, control of diabetes, and physical activity can lower cholesterol and triglyceride values. Adequate treatment of hypothyroidism can lower an elevated cholesterol. Cholesterol responds to reduction in dietary fat and cholesterol; triglycerides respond quite well to decreasing intakes of fat, sugar, and alcohol.
Both dietary cholesterol and dietary fat raise the serum cholesterol. Don’t be tricked by food labeling; some foods are labeled low in fat but are high in cholesterol, and vice versa. Egg yolks are very high in cholesterol, whereas potato chips are high in fat. Some special interest industries have falsely promoted over the years the idea that their products are part of a healthy diet. The egg industry in particular has financed research considered “junk science” by medical authorities. Egg yolks raise cholesterol, no matter that quantity or type of egg. Cow’s milk and most meats are very high in fat, ranging frequently from 50 to 80%.
Both soluble and insoluble fiber products lower cholesterol. One study showed that eating oatmeal 3 times a week for 6 months lowers cholesterol 10%, however that means no butter in the oatmeal. Bran products provide insoluble fibers, however bran muffins are often mixed with much fat, negating the positive effects. Fruits and vegetables provide soluble fiber (although fruits should be limited to 2 a day in the treatment of elevated triglyceride).
Adjuncts to dietary therapy can be included. Psyllium in doses of 5 grams twice a day, oat bran, pectin, and guar gum, can produce a 5-10% decrease in LDL cholesterol.
The 30% fat promoted by the American Heart Association for decades has been shown in studies to lead to no significant drop in cholesterol. Another words, it doesn’t work. 20% fat diets have a significant effect on lowering cholesterol. The Pritikin regression diet, the McDougall diet, and the Ornish diet, all high carbohydrate, low fat (HCLF diets), all less than 10% fat, have a major effect in achieving reductions of total cholesterol below 150 mg, and LDL cholesterol (bad cholesterol) below 100 mg. Nathan Pritikin published scientific studies in the 1970's showing that 85% of type II diabetics on oral medication and 50% on insulin can be off those medications within one month on the Prikin regression diet, and the figures remained similar at one year follow up. Dr. Dean Ornish published studies using cardiac cathaterizations showing that atherosclerosis in the coronary arteries can regress on the Ornish program. (Both programs include daily exercise, and the Ornish program includes relaxation anti-stress techniques).
These diets can be difficult to adhere to in the age of convenience stores and eating out. I have seen cases of a cholesterol level of 300 mg. dropping to 200 mg. in one month on this type of diet. The terms “high carbohydrate” if very misleading. They require almost exclusively complex, not simple carbohydrates and are also high in soluble and insoluble fibers. Many published studies publish misleading conclusions by comparing the Adkins diet (high in protein, low in all carbohydrates), or the Mediterranean diet (high in olive oil) with a diet that is high in all kinds of carbohydrates, complex and sugars, and then erroneously draw the conclusion that they are superior to the HCLF diet. There have been accusations and evidence that some of these misleading studies have been financed by the olive oil manufacturers.
In the 1960’s, the concept of lowering cholesterol by eating a lot of polyunsaturated fats (vegetable oils) was promoted by the American Heart Association. The studies showed it lowered cholesterol only 10% but increased the incidence of various cancers. Some of these fats we now know as “trans-fats” and they have gone from being recommended by health authorities to being banned in many areas. Nathan Pritikin was an early voice in pointing this out to the public in the 1970’s that substituting vegetable oils for saturated oils doesn’t work.
Vegetarian diets tend to be lower in fat or cholesterol SOMETIMES. Some vegetarians eat a lot of oils and dairy products, which negate the beneficial effects.
Olive Oil: Olive oil is a monounsatured fat, different from the polyunsaturated and saturated fats. There is evidence that it is better than saturated or poluunsastured fats. However in a direct comparison with true HCLF diets, they are second best.
Adkins diet: The debate about the Adkins diet goes back almost 4 decades. Dr. Adkins got a lot of attention when he promoted his products by saying you can eat all the eggs and butter, etc. you wanted. Although the Adkins diet does allow significant amounts of fat and is high protein, it severely restricts simple sugars, sharing in common an important characteristic of the HCLF diets. The publicity associated with the Adkins diet often says eat all the meat you want. The actual Adkins program as detailed in the various books gives examples of dinner meals consisting of 4 or 5 ounces of chicken or fish, and very insignificant amounts of whipped cream included in desserts. By eliminating ALL simple sugars, the diet is also eliminating a lot of products that are very high not only in fats but in salt – cakes, pies, cookies, etc. So the initial success of the Adkins diet is due to eliminating most sugar and a lot of fat from the diet, despite its reputation as a high fat diet. A lot of the initial weight loss is water weight because of the reduction in salt. Short term total cholesterol can be reduced; long term it depends on what type of foods one eats on the Adkins diet. If one truly eats large amounts of meat and fat, that type of diet has been proven rerpeatedly to be unhealthy in terms of both atherosclerosis and cancer. Long term studies of the Adkins diet and weight loss are not convincing.
Vegan or Vegetarian diets: In general, vegetarians and vegans have lower cholesterols and lower atherosclerosis disease rates than non-vegetarians and vegans. It really depends on the degree of adherence. If the diet includes more oils than the non-vegetarian or vegan, the benefit of the diet is partly negated. The inclusion of dairy products by some vegetarians is a story in itself. Of the HCLF diets mentioned above, the McDougal diet is a very low fat vegan diet with the addition of no oils and very limited sugars. The Ornish and Pritikin regression diet approaches this type of diet, but does include relatively small amounts of non-vegan products.
WHAT DOESN’T WORK:
Cutting down to 3 eggs a week doesn’t work. An egg contains over 225 mg. of cholesterol. Decades ago a cardiologist in Richmond, Virginia, experimented on himself and drew daily cholesterol levels while eating 6 eggs a day. There was a 50 mg. increase in cholesterol within a few weeks, at which point he quit the study. I know about this because he was my instructor in medical school.
Substituting polyunsatured fats (as the American Heart Association recommended for a few decades) not only doesn’t work; it causes an increase in cancer. This was known in the early 1970’s. To this day, a significant portion of the public thinks polyunsaturated fats such as various vegetable fats are healthy.
Cutting fat but continuing to eat high amounts of simple sugars will prevent weight loss and tends to keep the cholesterol level up.
GENETIC CONDITIONS AND CHOLESTEROL
One in 500 Americans have a gene for dominant hypercholesterolemia. This frequently leads to cholesterol levels of over 300 mg, and if not corrected, a high incidence of atherosclerosis and heart attacks. Studies have shown that the gene does interact with diet. Their grandparents may have had levels in the 200’s, whereas they have levels in the 300’s. If a person has a double dose of the gene (usually one from each parent), a very rare condition, his or her cholesterol can exceed 1000, and yes, it does interact with the diet, but other measures have to be taken to prevent early illness.
IT "ONLY" TOOK 6 DECADES
The pathologist Dr. Aniltsichkow first discovered that role of cholesterol in atherosclerosis in 1914. His studies were prominently published in Germany. In spite of that, it took 6 decades to receive increasing attention, to the point now that many heart attacks are now avoided by lowering cholesterol levels.
The scientist Nathan Prikin accelerated this awareness in the 1970’s with his research.
Conclusion: The scientific discoveries about atherosclerosis first made in 1914 are now proven beyond any doubt. The potential remains that most atherosclerosis, a leading cause of death, can be prevented.