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.

High Cholesterol Under Treated in Many Americans

NEW YORK (Reuters Health) - A US study on cholesterol released today contains both good and bad news:

The good news: Between 1999 and 2006, the number of adults in the US with high levels of artery-clogging LDL cholesterol, the "bad" cholesterol, decreased by about one-third.

The bad news: A high percentage of adults still are not being screened or treated for high cholesterol levels, putting their health in jeopardy.

Adults at greatest risk for heart attack and other heart-related "events" continue to have the highest prevalence of high LDL cholesterol, Dr. Elena V. Kuklina and associates at the US Centers for Disease Control and Prevention in Atlanta found.

The researchers studied trends in the prevalence of screening, current use of cholesterol-lowering medication, and high LDL cholesterol levels across four periods: 1999-2000, 2001-2002, 2003-2004, and 2005-2006. Overall, there examined data on more than 7,000 adults.

Between 1999-2000 and 2005-2006, the prevalence of high LDL cholesterol levels fell from about 32 percent to 21 percent, the investigators report in Wednesday's edition JAMA (Journal of the American Medical Association).

The prevalence of high LDL cholesterol varied significantly by risk category, however. In 2005-2006, the prevalence high LDL-cholesterol was 59 percent in individuals at high risk for heart-related events, namely those with a history of heart disease, chest pain, heart attack, stroke or diabetes.

The prevalence of high LDL cholesterol was 30 percent in those at medium risk for heart problems and 11 percent in those at low risk. Individuals were stratified as medium or low risk depending on their number of such risk factors as cigarette smoking, high blood pressure, family history of heart problems, and LDL and "good" HDL cholesterol levels.

In the high-risk group, more than 35 percent had not been screened for high cholesterol in the last 5 years and nearly 40 percent were either untreated or inadequately treated for high cholesterol. Roughly 20 percent of high-risk subjects were candidates for statins or other cholesterol-lowering therapy but were not receiving it.

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Kardea Nutrition-enabling a scientifically-validated nutritional approach to cholesterol management and cardiovascular health---works alone or as a complement to conventional pharmaceuticals. See Kardea White Paper.

Looking Beyond Lowering LDL Cholesterol

The risk of developing cardiovascular diseases is typically assessed based on a standard cholesterol test measuring LDL (low-density lipoprotein) and HDL (high-density lipoprotein) levels and then factoring advanced age, gender, family history of heart disease, high blood pressure, diabetes, and smoking. Taking these factors into account, LDL lowering targets can then be established, and a program of therapeutic changes in lifestyle and nutrition can be established. If these changes are unable to bring cholesterol levels in line, medications are routinely provided.

However, studies indicate that these risk factors can account for only a portion, perhaps 50%, of the incidence of coronary artery disease. The scientific community has continued its investigations, and is finding that a number of other risk factors can be identified through blood test. On its website, Berkeley Health Lab, a leading medical lab with an integrated program for cardiovascular treatment, identifies many of these important factors including:

Size of LDL Particles: Some LDLs Are Worse Than Others

• Small LDL particles can cause plaque build up to progress much faster because they can enter the artery wall easier than large LDL particles
• Too many small LDL particles can increase your risk for a heart attack beyond any other risk factors you may have, such as smoking, high blood pressure, diabetes, etc.
• Certain medications, proper nutrition, and regular exercise can help your body produce fewer small LDL particles

Size of HDL Particles: Some HDLS Are Better Than Others

• HDL helps to protect against progression of plaque build-up in the artery wall
• HDL2b is the workhorse of all of the HDL particle types. It has the ability to pick up and remove cholesterol
• Certain medications, improved nutrition, loss of body fat, stopping tobacco use, and increased physical activity are some ways that HDL-C and HDL2b can be improved

Apolipoprotein B: Accurate LDL Particle Number

• ApoB is a direct measurement of the amount of LDL ("bad" cholesterol) particles
• A high apoB number indicates increased risk for heart disease
• Improved eating habits, increased physical activity, and loss of body fat are some lifestyle changes that improve apoB
• Your physician uses apoB to determine if certain medications are needed and to monitor their effectiveness

C-Reactive Protein-hs (CRP)

• High levels of CRP indicate inflammation within the body due to infection or tissue injury; it can also predict heart disease risk levels
  Certain medications may help reduce this risk
  Certain foods have anti-inflammatory benefits

ApoE Genotype

• ApoE is a genetic test that plays a role in helping to identify how people respond to different amounts of dietary fat. Your body's response to dietary fat impacts the formation of small or large LDL particles
• There are 3 types of apoE genotypes: apoE2, apoE3 and apoE4
• People with an apoE4 have a greater risk for heart disease
• ApoE can be used to help guide the right nutrition plan for you

Other risk factors measurable through blood tests also are discussed on this site.

Overall, most of us typically receive the standard test for cholesterol, with these more thorough tests reserved for those individuals at high risk. Yet, for those of us interested in the information needed to optimize our long term health, this more complete assessment can be very useful. Check with you healthcare provider about obtaining these more extensive blood test to better direct your unique course for optimizing your health.

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.

"Cholesterol Drug Bombs"-New York Times Editorial Misses Opportunity

Yesterday, the New York Times editorial board wrote "there have long been suspicions, but it was still very disturbing to learn this week that a heavily promoted cholesterol-lowering drug had flunked a clinical trial of its effectiveness in reducing fatty deposits in arteries....The drug, Zetia, and a combination pill that contains it, Vytorin...generated more than $5 billion in sales last year."

You probably know the ads for Vytorin. They have run on T.V., in magazines and on-line. They certainly are clever, creative and very expensive. According to Nielsen Monitor-Plus, in 2006 the companies spent $136.3 million to advertise Vytorin and $115 million from January to October of 2007.

Vytorin combines Zocor, a statin produced by Merck (and also marketed by generic drug manufactures and sold at lower prices) with the Schering-Plough's Zetia. Statins work by reducing the production of cholesterol in the liver. Zetia works to reduce the absorption of dietary and liver-produced cholesterol from the intestines into the blood stream.

The study compared the effects of treating patients with Vytorin, the combination drug, with a statin alone. The patients all had abnormally high LDL cholesterol. In the study, LDL cholesterol was reduced more significantly by Vytorin than with the statin alone. These results are consistent with the results of a number of other studies.


It also was hypothesized that the added cholesterol-lowering effect of Vytorin would lead to a more significant reduction of arterial plaque growth. This relationship did not hold. The lower cholesterol achieved by the Vytorin did not yield a reduction in plaque build-up as compared to the statin only. In fact, the Vytorin group was found to have a more rapid development of plaque than the statin-only group.

The Times reports that these companies had been “cynically sitting on the results for more than a year” while spending hundreds of millions of dollars to convince consumers that the Vytorin is a preferred cholesterol drug. This certainly is a very legitimate criticism.

The Times continued that "the findings also raise doubts about the current belief that lowering cholesterol is the key to cardiovascular health. The study showed that Vytorin reduced bad cholesterol significantly more than Zocor alone. The problem was that it failed to reduce the formation of plaque."


And here is perhaps were the Times should have been somewhat more careful. This study now represents a single set of data among a sea of data that concludes lower LDL cholesterol lowers the risks of heart attacks and strokes. Numerous studies also indicate that LDL cholesterol above 100mg/dl will lead to the development of arterial plaque.

Instead of casting doubt on the general wisdom of cholesterol management, the Times would have served the public well by offseting the barrage of pharmaceutical advertising and reinforce the well-documented science regarding natural alternatives to cholesterol management. An extensive NIH report (http://www.nhlbi.nih.gov/health/public/heart/chol/chol_tlc.htm), for instance, concludes that the "amount of LDL reduction from Therapeutic Lifestyle Changes compares well with many of the cholesterol-lowering drugs." Among the recommendations are the consumption of certain positive nutrients such as plant sterols, soluble fibers, monounsaturated fats in place of saturated and trans fats, and Omega-3s. Needless to say, weight management and exercise is part of the NIH recommendations.

For more information on natural cholesterol management nutritients: http://www.kardeanutrition.com/cholesterol/program.aspx

Soluble Fiber--From Hype to Health

Take a walk through the grocery aisle, and you will quickly find many products claiming to be heart healthy.

For many of these products, the heart healthy claims flows from two essential nutritional characteristics. They are low in saturated and trans fats, and they deliver levels of soluble fiber sufficient to meet certain FDA-allowed heart health claims. To make these claims, the FDA requires that the products deliver in each serving at least .75 grams of soluble fiber from oats or barley, or 1.7 grams of soluble fiber from psyllium.

For those of us seeking measurable improvements in our cholesterol levels, success requires consuming substantially greater levels of soluble fiber. The National Cholesterol Education Program of the National Institutes of Health recommends 10-25 grams per day. Depending on your chemistry, consumption at these levels can lower LDL cholesterol by up to 8-10%. Some studies have suggested that results could be more significant.

How much oatmeal is required to reach 10 grams of soluble fiber? Roughly 5 servings, or about 2 lbs of prepared oatmeal. For 25 grams, you would need to consume about 5 lbs of prepared oatmeal, or about 2000 calories per day from oatmeal. Nay!

While oats certainly are a good starting point, I begin the day with a heaping tablespoon (=3 teaspoons) of whole psyllium husk. Psyllium seed husks are nature's most concentrated source of cholesterol-lowering soluble fiber. Where oats are only about 5% soluble fiber, psyllium husks are about 60%. With a tablespoon of psyllium husk, I start the day with 9 grams of soluble fiber (note: start with a teaspoon and work your way up).

5-6 servings of fruits and vegetables through the course of the day gets me another 5-6 grams.

From here, I shoot for the upper levels of the cholesterol-lowering soluble fiber targets. Success typically requires some culinary creativity and an understanding of the sources of soluble fiber.



Here is one recipe that you may find a useful addition to your weekly food choices:

Barley Pilaf
4 Servings of About 1 Cup Each

Barley never came to my mind as something I would crave. Yet, I discovered that barley stands side-by-side with oats as an FDA-endorsed food for promoting heart health by lowering cholesterol. I have since set out to explore how barley could be enjoyed in something other than a malted beverage.

As it turns out, a barley pilaf can be a delicious alternative to the rice, potato or pasta “starch” in protein/starch/vegetable triad my mom insists constitutes a meal.

A pilaf can be cooked to complement any number of dishes. Adapt by incorporating any number of spices. Start with the basic pilaf and create from there.

So, you ask "why don't more people eat barley." Part of the answer lies with the fact that cooking barley can be a bit tricky. If you're not careful, you might find your pilaf with hot cereal qualities---perhaps great for a cold morning but not the best for a dinner. But if you take a bit of care, you barley pilaf can be a great nutritious alternative to high glycemic, low fiber carbs.

Ingredients
1 Cup Rinsed Pearled Barley
2 Cups Water
1 Small Onion-Finely Chopped
2 Tablespoons Extra Virgin Olive Oil (preferably fortified with plant sterols)*
½ Teaspoon Turmeric
Salt & Pepper to Taste

*to double-up on the cholesterol lowering abilities of this dish, I formulated an extra-virgin olive oil with added plant sterols. This olive oil is available through the Kardea Nutrition website
http://www.kardeanutrition.com/products/food.aspx . If you want to reduce total fat, cut recipe to 1 tablespoon of oil.


Direction
Heat a sauce pan over medium heat. When pan is hot, add olive oil and chopped onion. Saute for a few minutes. Add rinsed pearl barley and saute for 5 or so minutes, stirring regularly and making sure that barley does not burn or stick to bottom of pan. Add turmeric and then water to the hot barley and stir. Cover, lower heat and cook until tender but still a bit chewy (30 minutes). Remove cover and on very low heat, let steam escape. Periodically fluff to prevent sticking to bottom of pan. Serve when barley appears about the consistency of steamed rice. This all may sound a bit cumbersome, but it works. The turmeric also give the barley a beautiful yellow color, accenting the visual appeal of an entire meal.


Nutritional Facts
(about a cup of cooked barley pilaf)
Calorie: 240 Calories from Fat: 70
Total Fat: 8g from olive oil; monounsaturated: 5.7g; polyunsaturate fat: 1.15g; saturated fat: 1.15g (4.3% of total calories); Trans fat: 0.0g.
Cholesterol: 0.0
Total Carbohydrates: 40g; Total Fiber: 8g; Soluble Fiber: 2g.
Protein: 5g.
Plant Sterol: .25g

Stepping-Up
You can try adding any number of spices. Try curry or cumin when serving lean meats or roasted root vegetables. Try ginger and currents when serving fish. Serve with a kidney bean chili or black bean salad (recipe in next blog) to create a meal that delivers 3-4g of soluble fiber.

Do You Have A Great Barley Recipe? Can you improve this recipe? Post your thoughts and recipes to this blog to share with the Kardea community.