Beyond Bad Cholesterol---Low Good Cholesterol May Be Greater Issue

As scientific knowledge advances, we gain a better understanding of the cholesterol challenge. Total cholesterol is no longer the focus. A primary focus on the absolute levels of LDL (bad) cholesterol is evolving to heightened interest in the LDL/HDL ratios, the total levels of HDLs (good cholesterol),the composition of the LDL cholesterol itself and the levels of inflammation. Here at Kardea, we continue to provide you information on the evolving science. The report below suggest that low HDL is a critical factor ---- perhaps more important than elevated levels of LDLs. From a treatment perspective,however, we simply have more tools --- both nutritional and pharmacological---to address elevated LDLs than to raise low HDL levels.

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Taking a statin to lower LDL or ‘bad’ cholesterol is of limited use in warding off the risk of heart attacks and cardiovascular disease unless low levels of HDL or ‘good’ cholesterol are also addressed, researchers from Tufts Medical Center in Boston, US have found.

The research team led by Dr Richard Karas, professor of medicine at Tufts University School of Medicine, examined the relationship between HDL cholesterol (HDL-C) and cardiovascular disease (CVD) risk in patients taking statins. While statin therapy does reduce CVD risk, the incidence of CVD events in statin-treated patients remains unacceptably high, they observed.

Karas' team identified 20 eligible randomised controlled trials of statins, with 543,210 person-years of follow-up and a total of 7,838 myocardial infarctions. The analysis revealed a significant inverse association between HDL-C and the risk of myocardial infarction. Every 10mg/dL reduction in HDL-C was associated with 7.6 and 7.8 more MIs per 1,000 person-years respectively in patients taking statins and in non-statin controls.

At the same time, statin treatment cut the risk of MIs by a median of 4.4 per 1,000 person-years.“While statins overall prevent four heart attacks per 1,000 patient-years, these new findings demonstrate that a 10-point higher HDL-C level could save an additional eight heart attacks per 1,000 patient-years, which indicates that, even if patients are on a statin, if they have low HDL-C, they may need more than just statins to significantly reduce their risks,” Karas commented.

“We believe most clinicians will be surprised to see the magnitude of the effect of low HDL-C on heart attack risk and how little statins impact the risk associated with low HDL-C,” he said.

The analysis also explored the association between HDL-C and cardiovascular disease, as well as coronary heart disease death, CVD death and all-cause death. In all these cases, the findings indicated that risk increased as the levels of HDL-C fell, and there were minimal differences between patients who were or were not taking statins.

Data from the Tufts Medical Center study were released at the American Heart Association Scientific Sessions 2009 in Orlando, Florida.

Strategies to Increase Good HDL Cholesterol

When it comes to cholesterol, most people think lower is better. But when we're talking about the cholesterol in our blood, it's a bit more complicated.

Low-density lipoprotein, or LDL, is known as the "bad" cholesterol and high-density lipoprotein, or HDL, is known as the "good" cholesterol. LDL optimally should be less than 100 mg/dL (milligrams per deciliter)---above this level, some amount of arterial plaque (the stuff that causes blocks in the arteries that can lead to heart attacks and stroke) is likely to develop. You and your doctor may or may not seek to lower your cholesterol levels if they are higher. This depends on a variety of risk factors. To assess your maximum LDL targets, click to the Kardea LDL Cholesterol Calculator based on the recommendations of the National Cholesterol Education Program. And if you are at high risk of heart disease, you and your doctor may seek to drive your cholesterol below 70mg/dL.

HDL cholesterol removes excess cholesterol from the blood, which slows the build-up in the arteries and ultimately lowers heart disease risk. Since estrogen increases HDL, women tend to have higher levels than men. Women should strive for an HDL above 50 mg/dL and men above 40 mg/dL. While genetics plays a role in your HDL level, there are some things you can do to modestly boost a sagging HDL:

• Lose weight if you're overweight. Exercising and cutting a few calories can give HDL a little boost, especially if you carry most of your excess weight in your abdomen.
• Quit smoking. Smoking, as well as secondhand smoke, can lower HDL.
• Recognize that different types of fats affect your HDL levels. Healthy fat choices such as omega-3s found in fish and monounsaturated fats found in olive oil and canola oil, nuts, seeds and avocados should be used---replacing the satured and trans fats found in processed foods, certain meats and dairy products.
  • Alcohol can raise HDL. If you can safely fit alcohol into your eating plan, keep it moderate -- no more than one drink a day for women and two drinks for men.

Also, you can consider the use of niacin as nicotinic acid. Available as both a supplement and a prescription medication, this form of niacin can significantly raise your HDLs. For an overview on niacin, read Kardea's discussion paper. And remember, in developing a program that optimizes your heart health and cholesterol profiles, it is best to collaborate with your health care professionals.

Lowering Cholesterol: A Piece of the Heart Health Puzzle

The relationship between LDL cholesterol and cardiovascular diseases has been well-documented and summarized by the NIH's National Cholesterol Education Program.

Epidemiologic studies (i.e. research that associates the lifestyles of different populations or groups to a disease), laboratory studies (i.e. research into the effects of certain nutrients or medication on cells outside the body) and clinical studies (research on the effects of certain nutrients or medications on a living person) all show that cholesterol is a critical factor in the development of atherosclerosis.

Atherosclerosis occurs when plaque builds up on the walls of your arteries. This plaque leads to a narrowing and ultimate closing of an artery. Plaque also can break free of the arterial wall. It then can lodge further down your artery, causing a blockage that can lead to a stroke, heart attack, or a blood clot in your arms, legs or other parts of your body.

National Cholesterol Education Program Summary of Research

• Studies across different populations reveal that those with higher cholesterol levels have more arterial plaque and heart disease than those with lower levels. People who migrate from regions where average serum cholesterol in the general population is low to areas with high cholesterol levels show increases in their cholesterol levels as they acculturate. These higher levels in turn are accompanied by higher levels of heart disease.
• Atherosclerosis often can be identified in adolescence or early adulthood. The cholesterol level in young adulthood predicts development of heart disease later in life. In three prospective studies with long-term follow-up, detection of elevated serum cholesterol in early adulthood predicted an increased incidence of heart disease in middle-age.
• The power of elevated LDL to cause heart disease has been shown most clearly in persons with genetic forms of very high cholesterol. In these persons, advanced coronary atherosclerosis and premature heart disease occur commonly even in the complete absence of other risk factors. These disorders provide stronge evidence that LDL is a powerful cause.
• Since LDL-cholesterol levels of less than 100 mg/dL throughout life are associated with a very low risk for heart disease in populations, they can be called optimal. Even when LDL-cholesterol concentrations are near optimal (100–129 mg/dL), plaque formation occurs; hence, such levels must also be called above optimal. At levels that are borderline high (130–159 mg/dL), plaque formation proceeds at a significant rate, whereas at levels that are high (160–189 mg/dL) and very high (above 189 mg/dL) it accelerates further.
• A large number of clinical trials on cholesterol-lowering therapy have been carried out over the past four decades. The initial encouraging findings of earlier trials have recently been reinforced by the robust findings of a large number of studies.
  

The Research in Context: Only A Piece of the Puzzle

Lowering LDL cholesterol is not a guarantee of cardiovascular health. Many people on cholesterol-lowering medications still suffer heart attacks, strokes and other cardiovascular challenges. Similarly, LDL cholesterol levels above the "optimal" levels should not necessarily require an individual to proceed to a lifetime of cholesterol-lowering medications. Each of us should discuss this carefully with our medical providers.

In these conversations, however, you should recognize that cholesterol-lowering is only one piece of the puzzle. Some things to consider:

• Once built-up in your arteries, plaque is difficult to remove. Cholesterol-lowering therapies may only serve to reduce further development, but not fully remedy arterial health.
• The medical community also is investigating the role that different types of LDLs might play in the development of both plaque itself and the ability for plaque to remain “stable” and not break free from the arterial wall. This may be a factor even if LDL levels are low.
• Low levels (below 40mg/dl) of HDL cholesterol have been shown to be a risk factor for heart diseases and high levels (above 60mg/dl) have been associated with reducing the risk of heart disease and plaque development.

Beyond cholesterol management, cardiovascular health flows from different hereditary, environmental and lifestyle factors. It is a complex equation.

The important point: cholesterol management should be thought of as a lifetime approach, starting in your teens, to maintain cardiovascular health. Like weight-management and physical fitness, cholesterol management and its nutritional tools can promote long term health.

Natural Cholesterol Management - Numbers are In

In a four month period, I naturally lowered my LDL (bad) cholesterol from 161mg/dl to 131mg/dl (about 19% improvement), increased my HDL (good) cholesterol from 55 to 61 (about a 10% improvement). Total cholesterol was reduced from from 228 (it had been as high as 239) to 201. I am not yet at the "under 200" target, but with my relatively high HDLs and declining LDLs, I was now closing in on some desireable cholesterol levels.

I achieved these goals with a less-than-disciplined, natural approach combining plant sterols, viscous soluble fiber and low levels of immediate release niacin from nicotinic acid.

I always have eaten fairly well. Low in terms of red meat and dairy, low in terms of saturated fats, processed foods and dietary cholesterol. Mediterranean cuisine also has long been a personal preference, and I use olive oil (and occassionally canola oil) in all cooking and food prep. I also eat a fair amount of vegetables and whole grains, and lots of fruit.

My internist had suggested that I might need to consider the use of a medication to achieve better cholesterol levels. As an otherwise healthy 49 male, I was not ready to start a lifetime of medication to create healthier cholesterol levels. I began a search for the alternatives, and found that a number of nutrients ---viscous soluble fibers, plant sterols, niacin and Omega-3 fatty acids --- can collectively enable an individual to substantially improve one's blood lipid profiles.

So, I began developing a personal program that incorporates these nutrients in foods and supplements. More importantly, I was looking to enjoy these foods (food and cooking are my pre-occupation and a source of daily joy). With my somewhat less-than-disciplined approach to consuming soluble fiber, plant sterols and niacin, I achieved the results noted above.

Note on full disclosure: While I weigh about the same amount, I did increase the frequency of exercise from 2 to 4 days per week. My workout intensity also increased.

I am now looking to refine my approach to further improve my blood lipid levels. As someone with year's of experience in the natural and gourmet foods, I also decided to create Kardea Nutrition to develop products that comfortably fit into my daily eating habits (and hopefully yours!). I also do not want these foods to lead to an increase in the total level of calories I take in each day.

My first set of products should be available in early February, but early in Janary, you will be able to log onto my website to see what's coming (http://www.kardeanutrition.com/).

Overall, I am sincerely interested in networking with others that are attempting to manage cholesterol levels naturally. Let's share what is working.....and based in part on these exchanges, I will be developing other foods and supplements that strive to meet the combined goals of delicious, natural, calorie-mindful and effective in terms of natural cholesterol management.