ASK THE DOCTOR: The skinny on cholesterol-lowering drugs
By DR. JIM MITTERANDO
The Patriot LedgerQ. I'm taking Lipitor for high cholesterol. Do I need to worry about the reports I've read of Baycol causing deaths? And do I really need to take this medicine?
A. Baycol was withdrawn in the United States because it was associated in rare cases with death caused by severe muscle breakdown called rhabdomyolosis. Baycol belongs to a popular family of cholesterol-lowering medications called "statins."
Statins, including Lipitor, Zocor, Pravachol, Mevacor and Lescol, are popular drugs because they can lower cholesterol better than other kinds of drugs and are pretty well tolerated. These other statin drugs have been associated with rhabdomyolosis, but less frequently than Baycol.
People taking a combination of a statin plus another cholesterol medicine such as niacin (Niaspan) or fibrate (Lopid or Tricor) are more likely to have muscle aches or rhabdomyolosis.
You should talk to your doctor about your concerns. Cholesterol management is part of lowering your risk of heart disease, and it's important to understand all the factors involved.
Heart disease kills almost 1 million Americans each year, more than all cancer deaths combined. Many of these deaths occur because fatty cholesterol-laden deposits (plaques) have accumulated on the walls of the patient's arteries (atherosclerosis), resulting in narrowed or blocked arteries.
Atherosclerosis is a silent, painless process that results in reduced blood flow. If you have reduced flow in the arteries around your heart, it can lead to a type of chest pain called angina.
As a plaque grows, the lining of your artery becomes roughened. A tear or rupture in the plaque may cause a blood clot to form, which can block the flow of blood or break free and plug an artery downstream.
If the flow of blood to part of your heart is stopped, you'll have a heart attack. If blood flow to part of your brain stops, you'll have a stroke.
This is a preventable condition, and cholesterol plays a part.
Cholesterol is one of two kinds of fat called lipids that circulate in your blood. Triglycerides are another form of fat that moves through your blood as transportable fuel used for energy.
Most of the cholesterol in your body is made by your liver from saturated fat in your diet. Some cholesterol also comes from foods such as eggs, meats and dairy products.
There are two important kinds of cholesterol:
- LDL cholesterol is often called "bad cholesterol" because it transports cholesterol to sites throughout your body, where it's either deposited or used to repair cell membranes. Like hard water causing lime to build up inside plumbing, LDL cholesterol promotes accumulation of cholesterol in the walls of your arteries.
- HDL cholesterol is often called "good cholesterol" because it helps clear excess cholesterol from your body.
You may have high LDL cholesterol as a result of your genes or lifestyle choices, or both. You can be born with cells that simply don't remove LDL cholesterol from your blood efficiently, or with a liver that produces too much cholesterol.
Genes, poor diet and inactivity can also cause low HDL cholesterol, which raises the risk of heart disease by not being available to clear cholesterol buildup.
The numbers:
It's best when your total cholesterol (the sum of HDL, LDL and triglycerides) is below 200. Between 200 and 239 is borderline high. More than 240 means you are at increased risk for heart disease.
LDL cholesterol less than 130 is best, with 130 to 159 being borderline high. LDL of 160 or more means you are at increased risk.
An HDL below 40 increases risk, whereas an HDL above 60 reduces risk.
It's best to have triglycerides below 200.If tests show your numbers are abnormal, your doctor will recommend lifestyle changes such as weight loss, diet and exercise, as well as further testing.
If your numbers are normal, they only need to be checked every five or six years because they do not fluctuate unless you make drastic diet or weight changes.
Recently, patients have asked me about blood tests for homocysteine, C-reactive protein and apolipoprotein A, which I feel are not necessary and do not change the management of cholesterol problems.
While cholesterol is an important health concern, it's unfortunate that it seems to attract more attention than the more critical heart disease risk factors that include smoking, diabetes, high blood pressure, obesity and inactivity. People often seem to be very concerned about their cholesterol level while they continue to smoke a pack of cigarettes daily and need to lose 30 pounds.
Often, when a patient loses weight, eats right and starts to exercise, the cholesterol falls in line. But it's the American way that we want pills to lower cholesterol instead of putting in the effort to change our ways.
About half of all Americans have a higher-than-desirable blood cholesterol level but most do not need to be on cholesterol-lowering medication.
The recent news of deaths associated with Baycol highlights that people need to do more before resorting to medications.
Statins are popular drugs because they can lower cholesterol by 30 percent to 50 percent by reducing the liver's production of cholesterol. Despite the potential for rare side effects, I do find them to be safe and well-tolerated.
Generally, doctors are more aggressive with cholesterol treatment when people have a history of atherosclerosis, heart disease, stroke, diabetes or several risk factors for heart disease, such as smoking, hypertension and a strong family history of heart disease.
But the first treatment for high cholesterol is always diet, weight loss and exercise, which can reduce cholesterol by 5 to 10 percent. If these basic lifestyle changes fail to bring the cholesterol into a desired range, then medications are started if the patient has significant risk factors for heart disease as well.
What has been controversial is when to treat people with elevated cholesterol who do not have heart disease. If you ask 10 different doctors you may get 10 different answers. If you have more than two or three risk factors for heart disease and have high cholesterol, you may benefit from taking cholesterol-lowering medications. This is something to discuss with your doctor.
I feel that many physicians are not treating enough people who have heart disease with statins, but are overtreating people with statins who have high cholesterol and only a few risk factors.
My next article in two weeks will discuss further dietary changes and drug alternatives to lower cholesterol and possibly the risk of heart disease.
Q. What can I do to lower my cholesterol without drugs?
A. Two weeks ago, I answered a question about the risks of cholesterol-lowering drugs and goals for treating high cholesterol.
Today, let's talk about diet and lifestyle changes that will bring your cholesterol down and improve your health.
An alarming fact is that one third of Americans are now obese. Obesity lowers the good HDL cholesterol, raises the bad LDL cholesterol and elevates the fats in your blood called triglycerides.
Being inactive and smoking are two serious mistakes people make with their health. An inactive lifestyle lowers HDL. Smoking cigarettes damages the lining of blood vessels that can contribute to buildup of cholesterol plaques and is a leading cause of heart attacks and strokes. Smoking can also lower HDL by as much as 15 percent. Quitting smoking is imperative to having a heart-healthy lifestyle.
Aerobic exercise at least three to four times per week will raise your good HDL cholesterol. Furthermore, your blood pressure and blood sugar will be better controlled, lowering your risk of hypertension and diabetes. If you lose weight and exercise, you can decrease your total cholesterol by at least 10 percent.
Changing your eating habits can lower your cholesterol by another 5 to 10 percent. Here are some tips:
- Limit saturated fats, like meat fat, dairy fat (cream, butter and cheese), palm oil, coconut oil (in baked goods) and chocolate candy
- Limit or eliminate foods with trans-fatty acids often labeled as "partially hydrogenated vegetable oils" such as margarines, shortenings, crackers, cookies and fried foods
- Use monounsaturated fats such as olive oil or canola oil for cooking, instead of corn oil or peanut oil
- Eat more fiber, including at least five to seven servings of fruit and vegetables daily, which can raise HDL and may lower LDL
- Eat more broiled or grilled fish and chicken breasts
- Eat less meat and make meat the side dish with vegetables and grains the main dish
- Add beans to leafy salads, pasta salads and stews. Chick peas, kidney beans and navy beans have been shown to reduce LDL
- Eat soy products, which may lower total cholesterol, LDL and triglyecrides and improve HDL.
Cholesterol naturally occurs in foods made from animals, such as meat, eggs and cheese. Plant foods contain no cholesterol. Eating a high-fat, high-cholesterol diet contributes to an increased blood cholesterol level. Saturated fats and trans fatty acids are particularly notorious for raising blood cholesterol levels.
Not all fats are bad, though. Monounsaturated fats found in olive oil and canola oil and nuts (almonds, pecans, cashews, walnuts and macadamia) lower total and LDL cholesterol, although you should eat them in moderation.
Eating some types of fish also lowers your risk of heart disease.
The key seems to be a type of polyunsaturated fat called omega-3 fatty acids. This heart-protective fat lowers triglycerides and may reduce the risk of blood clots. Omega-3 fatty acids are found in cold-water fish including salmon, mackerel, trout, swordfish, bluefish and Atlantic herring.
Omega-3s are also present in smaller amounts in green leafy vegetables, soybeans, walnuts, flaxseed and canola oil.
Omega-3 fatty acids also are available in pill form but can cause fishy breath. Flaxseed oil pills are also available. I often recommend these supplements when treating high cholesterol and high triglycerides.
It's important to limit all types of fat - saturated, polyunsaturated, trans fatty acids (trans fats) and monounsaturated - to no more than 30 percent of your total daily calories.
The recent fad diets high in fat and low in carbohydrate and low in fiber such as the Atkins diet can increase your cholesterol and triglycerides and should not be used for long-term, if at all.
The Ornish diet is very low in fat, limiting it to 10 percent of caloric intake with a vegetarian diet which can prevent heart attacks in patients with heart disease.
A Mediterranean diet with monounsaturated fats such as olive oil plus vegetables and beans also reduces heart disease and is quite palatable.
You also may want to eat less cholesterol-rich food. Your daily cholesterol intake should be 200 milligrams or less.
Egg yolk, shrimp, lobster, calamari and liver have high levels of cholesterol. Egg white has no fat or cholesterol and is also an excellent form of protein.
The new cholesterol-lowering margarines called Benecol or Take Control can reduce cholesterol and LDL by 10 to 15 percent, if used with meals, by decreasing the absorption of cholesterol in the intestine. They do not affect HDL or triglycerides. They cost about five times more than regular margarines.
Patients tell me that these new margarines taste just like butter and cook well. (Although one told me not to put in the micowave because it pops.)
Though garlic is touted as a panacea for cholesterol, studies have shown only limited benefits at best if you eat large amounts of raw cloves. (Unfortunately, cooked garlic loses that active ingredient but at least tastes good.)
I generally recommend a multivitamin for people with high cholesterol since it may decrease the risk of heart disease by decreasing homocysteine. The important ingredients are probably folic acid, B6 and B12 vitamins. I recommend any generic brand such as CVS or Walgreen's to save money.
Megavitamins provide no added benefit. In the past, I recommended the antioxidants - vitamin E and vitamin C - but they have proved disappointing in recent studies showing minimal or no benefit, and vitamin C may even be harmful at higher doses by possibly contributing to damage of the walls of arteries.
Vitamin E (400 IU) is safe and may be worthwhile if you have tried everything else. Vitamin A supplementation is not recommended.
Other antioxidants have not been proven to be effective. People with high cholesterol who have other risk factors for heart disease may consider taking a "baby" aspirin (81 mg) every day or every other day with food to decrease the chance of heart disease and stroke. Unfortunately, aspirin has its own risks, including stomach ulcers, kidney problems and bleeding. Stop this medicine if you develop stomach pain or black stools and contact your physician.
Dr. Jim Mitterando is a family doctor at Health Care South/Cohasset Family Practice and a staff member at South Shore Hospital in Weymouth.
Readers should send questions to: Ask the Doctor, The Patriot Ledger, P.O. Box 699159, Quincy, MA 02269-9159, or by E-mail to his attention at features@ledger.com.
Questions of general interest will be answered in this column. The information in this column is not intended to diagnose individual conditions, and individual replies are not possible. Readers should see their own doctors about specific problems.
Copyright 2001 The Patriot Ledger
Transmitted September 4, 2001