Women’s Health

Cholesterol & Triglycerides

In 2006 the American Heart Association reported that 51 Million women in the U.S. had elevated cholesterol levels. In general, elevated cholesterol levels increase the risk for heart disease, strokes and kidney disease, which is exactly why we need to learn more about it.

Cholesterol is a soft, waxy substance found in your blood and in all of your body’s cells. Cholesterol is important in forming the sheaths that surround nerves and also in the production of bile acids that are necessary for digestion. In addition to all that, cholesterol is a precursor to the production of estrogen, progesterone, and testosterone (yes, women need testosterone too!).

Cholesterol is normally made in the liver (about 1000 mg/day) and virtually all the cholesterol we require is made there. Unfortunately, we also get a lot of cholesterol from the foods we eat. In fact, the average American woman consumes over 200 mg/day in dietary cholesterol. Men generally consume more! Too much cholesterol is a major risk factor in the development of arterial narrowing—atherosclerosis—which leads to heart attacks, strokes, kidney disease and blindness.

Because cholesterol is a fat it can’t dissolve in your blood (remember oil and water don’t mix!). Cholesterol, therefore, gets transported through the bloodstream by attaching itself to a special “carrier” protein known as a lipoprotein. There are several kinds of lipoproteins, but for the purpose of our discussion we’ll focus on two—LDL (low density lipoprotein) or “bad” cholesterol and HDL (high density lipoprotein) or “good” cholesterol.

We have known for many years that plaque, the fatty substance that narrows arteries, is composed of a variety of fatty substances, among which are LDL cholesterol and triglycerides.

LDL (Low density lipoprotein) cholesterol—”bad cholesterol”

Low density lipoprotein (LDL) is the major carrier of cholesterol in the blood stream. If too much of the LDL cholesterol circulates in the blood stream it can build up and cause narrowing of the small and medium sized arteries leading to heart disease, strokes, kidney disease and blindness. Together with other substances LDL cholesterol can form what is known as “plaque”—a thick hard deposit that narrows the blood vessels. Oftentimes, areas of plaque formation stimulate a thrombus (or clot) to form thereby completely cutting off blood supply to the affected tissue. If this happens in the heart it causes a “heart attack”. The same process occurring in the brain is called a “stroke”. In both cases the tissue being supplied by that artery is being blocked and starved of oxygen and nutrients.

HDL (High density lipoprotein) cholesterol—”good cholesterol”

About 25 – 35% of blood cholesterol is carried by high-density lipoprotein. This cholesterol seems to protect against heart attack. Researchers believe that HDL cholesterol carries cholesterol away from the arteries and back to the liver. For this reason some doctors have referred to HDL cholesterol as the “janitors” of the blood stream. High levels of HDL cholesterol have been shown to be protective against heart attacks and strokes.

The current status of medicine is such that we have more tools to lower bad cholesterol than to increase good cholesterol (HDL). Most of the medications available to us (“statins”) lower LDL cholesterol with little effect on HDL cholesterol. There is some evidence that small quantities (one drink for women) of alcohol may be helpful. But be careful—large quantities of alcohol are definitely harmful! Hormone replacement therapy (HRT), if appropriate, can raise HDL cholesterol, but this may be offset by other disadvantages of HRT.

But the news here isn’t bad. While we may not yet be able to raise HDL cholesterol significantly there’s a great deal we can do, by working together, to sharply decrease your risk for a heart attack or stroke.

How does my diet affect my cholesterol?

We all get cholesterol from two different sources: our diet and what our liver makes. As I’ve mentioned earlier healthy livers make about 1000 mg of cholesterol a day. We also get cholesterol from the foods we eat. Most cholesterol comes from animal sources—egg yolks, meat, fish, poultry, seafood, and whole milk dairy products. Foods from plants (nuts, grains, seeds, fruits and vegetables) don’t contain cholesterol. The average American man consumed about 337 mg of cholesterol per day while the average woman consumes a little more than 200 mg per day. The American Heart Association recommends that you limit your cholesterol intake to 300 mg/day. However, if you are at risk for heart disease for other reasons (smoking, hypertension, family history, etc) you might consider limiting your intake even further. For specific recommendations please discuss this with your health care provider at our office.

How does exercise affect my cholesterol?

Regular physical exercise increases HDL cholesterol in some people. Whether or not it will affect your cholesterol in particular will need to be determined. However, since the goal is to lower your risk of cardiovascular disease and stroke, exercise is an important component of avoiding atherosclerosis and the risks of heart disease and stroke.

What about cholesterol and smoking?

Smoking tends to lower good cholesterol. Apart from that smoking is one of the major independent risk factors for heart disease and strokes.

When should my cholesterol be checked?

The National Institute of Health (NIH) recommends that women have their first cholesterol screening test at age 20. We will generally screen women according to their overall risk factors for cardiovascular disease. Among the issues we consider in determining how often to check your serum cholesterol are:

  • History of smoking
  • Alcohol abuse
  • Strong family history of cardiovascular disease and/or strokes
  • Hypertension
  • Obesity
  • Women at very low risk may be screened once in every 3-5 years. Women on cholesterol lowering medications will require more frequent screening.

What’s a normal cholesterol level?

Generally speaking women at low risk for cardiovascular disease should keep their total cholesterol level below 200 mg/dL, their LDL cholesterol below 130 mg/dL and HDL cholesterol at least 50 mg/dL.

If women have one or more risk factors noted above we recommend that the LDL cholesterol remain below 100 mg/dL. For women with multiple risk factors for heart disease and strokes we often suggest that the LDL cholesterol be kept under 70 mg/dL.

If I have an elevated cholesterol level what can be done about it?

Fortunately, there are a great many things that can be done to improver your cholesterol level. The goal is more than getting your “numbers” in the proper range. The real goal, after all, is to lower your changes for heart disease, strokes, kidney disease, blindness and their effects of atherosclerotic plaques.

There are many ways, other than medication, to lower your cholesterol and overall risk of atherosclerotic plaque formation.

Exercise and weight loss

The relationship between cholesterol and exercise has more to do with weight control than the exercise itself. However, it has been shown that in many individuals exercise itself raises HDL (good) cholesterol.

I see many women day in and day out that find theirselves at age 30 with a 5 or 10 pound weight gain since their last annual exam. They don’t understand why. Many insist that it’s their birth control pills. Others insist that they are probably hypothyroid. In most cases they’re wrong. For the vast majority of us, the same level of eating and lifestyle after the age of 25 – 30 leads to weight gain. The truth is that we live in a very sedentary society. As residents of Western New York we don’t get out much between November and April (almost half the year!). We have stressful jobs, but most of it involves sitting at a computer or standing in one place for long periods of time. The fact remains that as we age our metabolism slows down. At age 20 you may be able to “eat whatever I want” and get away with it—but for most of us that’s a short-lived luxury. As we age, unless we modify our diet and establish a regular exercise routine, we find ourselves gaining weight. MAKE AN APPOINTMENT WITH YOURSELF! Just as you set aside time to shop, watch your favorite TV program or answer e-mails, set aside 45 minutes or more at least 5 times a week and work up a sweat. If you’re 30 years old walking on a treadmill with a zero degree incline for 15 minutes is not exercise—its self-delusion. You need to get your heart rate up and break a sweat. Come in or call so we can specifically address this issue with you.

win.niddk.nih.gov/publications/for_life.htm

Dietary changes

Years ago researchers assumed that dietary cholesterol in such foods as meat, eggs, cheeses and whole milk was the main culprit in hypercholesterolemia. As our knowledge of cholesterol and heart disease improves we are beginning to understand that other dietary factors such as saturated and trans fats also play a key role in elevating one’s cholesterol. Saturated fats are found in meats, whole-fat dairy products and eggs. Trans fats are frequently found in an artificial form contained in hydrogenated oils found in margarine and many commercial baked goods and processed foods. The New York City Board of Health voted unanimously in December 2006 to phase out the use of artificial trans fat from all NY city restaurants by July 2008.

www.nyc.gov/html/doh/html/pr2006/pr114-06.shtml

The majority of Americans get their trans fats not from animal sources, but from cakes, cookies, crackers, pies and breads. It appears that high cholesterol levels are an unfortunate result of the luxuries of modern life

Stop smoking

Seriously….quit! It will not get easier than right now—except if you’re in the midst of a major personal or family crisis. But unless you’ve just lost your job, a family member, find yourself in the midst of breaking up a long-term relationship or caring for a sick family member you need to ask yourself if there’s really a better time to quit than right now. Life is stressful and smoking relieves that stress. Also, many women continue to smoke because they know it helps them control food cravings and allows them to keep their weight down. The problem is that smoking has devastating side effects. There are better ways to control your stress and your weight.

Medications

Despite your best efforts you may find that you are unable to significantly lower your total or LDL cholesterol with diet and exercise alone. There are several situations when you might be asked to seriously consider the use of a medication to lower your cholesterol in order to reduce your overall risk of coronary heart disease and strokes. These circumstances include:

  • Age — Women 55 years or older.
  • Family history — You have a father, brother or son with a history of coronary heart disease before age 55, or a mother, sister or daughter with coronary heart disease before age 65.
  • Smoking — You smoke or live or work every day around people who smoke.
  • High blood pressure — Your blood pressure is 140/90 mm Hg or higher, measured on two or more occasions.
  • HDL cholesterol — Your HDL cholesterol level is less than 40 mg/dL.
  • Diabetes — Your fasting blood sugar is 126 mg/dL or higher.

There are many cholesterol-lowering medications available—you can’t tune in to the evening news without stumbling onto the more heavily advertised ones.

Statins

These drugs work in the liver and are very effective in lowering LDL (bad) cholesterol. They have few short-time side effects and their long-term profile appears to be excellent. Despite their excellent safety, the decision to take any medication needs to be weighed against the potential harm of not taking that medication. Among the more common statins are Lovastatin (Mevacor), Simvistatin (Zocor), Atorvastatin (Lipitor), Fluvastatin (Lescol), Rosuvastatin Calcium (Crestor) and Pravastatin (Pravachol)

Clofibrate (Lopid)

This drug raises HDL cholesterol and lowers triglycerides.

Nicotinic acid (Niacin)

It’s important to distinguish FDA-controlled nicotinic acid from that found in health food stores. Unfortunately, health food store preparations are unregulated and may contain more or less than the amount prescribed. Nicotinic acid is available in several prescription forms (Niaspan, Euduracin). The major indication for nicotinic acid lies in its ability to increase HDL cholesterol.

triglycerides

What are triglycerides and what do I need to know about them?

Triglycerides are a type of fat. Most fat in foods, and in your body, takes the form of triglycerides. In summary, we “consume” triglycerides whenever we eat fat, store triglycerides (in fat cells) when we get “fat” and “burn” triglycerides (from fat cells) when we expend more calories than we ingest.

Triglycerides (TGs) are closely related to eating and the kinds of foods we eat. TGs rise dramatically after a simple-carbohydrate-rich meal—especially simple sugars and alcohol.. This is because sugars not used immediately for energy will be converted to triglycerides and stored as fat.

Some research has shown that people with above-normal triglyceride levels are at increased risk for heart disease. They’re also likely to have high total cholesterol, high LDL, and low HDL–all risk factors for heart disease.

What’s a normal level of triglycerides?

First of all, please remember that a triglyceride level is measured accurately only when you’ve been fasting for 8-12 hours.

  • Normal triglycerides ≤ 150 mg/dL
  • Borderline high 151 – 199 mg/dL
  • High 200 – 499 mg/dL
  • Very High ≥500 mg/dL

Do elevated triglycerides cause heart disease and strokes?

We do know that elevated triglycerides are linked to other abnormally elevated lipids and this may be responsible for the association between hypertriglyceridemia (elevated triglycerides) and coronary heart disease and strokes. We don’t know with certainty that elevated triglycerides are an independent risk factor for coronary artery disease and strokes.

What are the causes of triglyceride elevation (hypertriglyceridemia)?

Triglycerides levels can rise to abnormally high levels when someone eats a diet rich in carbohydrates (starches, sugar and alcohol) and/or saturated fats. This is especially true in women who are obese and don’t exercise. High triglyceride levels are also found in the following:

Diabetes
Kidney disease
Familial dyslipidemias (genetic)
Hypothyroidism
Estrogen replacement therapy
Tamoxifen

What are the recommendations if my triglycerides are elevated?

The answer is that it depends on your other risk factors for heart disease and strokes as well as how elevated.

With triglycerides in the 151-199 mg/dL range most experts emphasize weight reduction and increased physical activity.

When triglycerides are in the 200 – 499 mg/dL range emphasis is generally placed on lowering LDL cholesterol first, followed by the addition of nicotinic acid or fibrates, such as Lopid.

When triglycerides are over 500 mg/dL emphasis is placed in preventing pancreatitis by lowering triglycerides with a combination of non-drug therapy as well as the careful use of fibrates and nicotinic acid.

What are some ways I can lower my plasma triglycerides without medications?

Reduce saturated fat
Reduce the intake of simple carbohydrates (sugars and alcohol)
Start a regular exercise program
Control diabetes
Control your blood pressure
Control you “bad” (LD) cholesterol
Fish oil

There is evidence from multiple large-scale studies that intake of recommended amounts of DHA (docosahexaenoic acid) and EPA (eicosapentaenoic acid) in the form of dietary fish or fish oil supplements lowers triglycerides, reduces the incidence of heart attacks and heart rhythm disturbances, slows the buildup of arterial plaques and lowers blood pressure. I often recommend fish oil supplements. Many brands are available at pharmacies, grocery and health food stores. I recommend 2-3 grams per day of fish oil supplements with omega-3 fatty acids.