Cholesterol: More Than a Numbers Game

Heart disease and smoking
You can reduce your risk for heart attack much more if you quit smoking or lose weight.

By Dr. Richard W. Lord

We all know that high cholesterol puts patients at risk for heart disease. But how does high cholesterol stack up against other risk factors such as smoking, obesity and family history?

In my family medicine practice at Wake Forest Baptist Health, I like to discuss cholesterol in the context of other factors that put my patients at risk for a heart attack, stroke or other heart disease or vascular disease. Often I take them through a computer model that calculates their risk for heart disease including heart attack based on whether or not they smoke, their weight, age, family history and yes – their cholesterol level.

The model allows me to show my patients how their risk for heart disease and heart attack changes as they reduce their risk factors. For example, if you smoke, we can calculate how quitting will change your risk for heart attack. If you’re overweight, we can calculate the impact of losing weight. The same with your cholesterol level. There’s no doubt that reducing cholesterol will reduce your risk for heart disease. However, it turns out that you can reduce your risk for heart attack much more if you quit smoking or lose weight.

Once they understand the risks, I’ve had patients tell me they would rather quit smoking and hold off on worrying about their cholesterol. I can’t argue with that. Preventive medicine is about reducing risk.

[Try our online Cholesterol Reduction Calculator.] [More Health Calculators]

Remember, high cholesterol is not a heart disease. I want my patients to reduce their cholesterol level only because it will help them prevent heart disease and stroke. And I remind them too that high cholesterol is not an immediate threat to their health. Rather, it’s a problem over time. It’s over time that high cholesterol leads to plaque buildup in the blood vessels, and with that, heart disease, stroke and vascular disease.

Today, we measure cholesterol by the type of molecule that carries it through the bloodstream: low-density lipoprotein, or LDL, which I call “lousy cholesterol” because it causes plaque build-up, and high-density lipoprotein, or HDL, which I call “happy cholesterol” because it may reduce plaque buildup.

The guidelines for safe levels of cholesterol differ, depending on a patient’s overall health. In healthy patients, an LDL level of 130 or lower is fine. Because HDL protects against heart disease, the higher the better. We recommend a level of at least 35 and an ideal level of 65 or greater. The recommended level for LDL declines with other medical issues. Patients with diabetes, a family history of heart disease and other risk factors should keep their LDL levels at 100 or lower. And some physicians recommend an LDL level of 70 or lower for patients who have suffered a heart attack.

The guidelines could change again soon. LDL comes in small particles and large particles. Research suggests that small particles of LDL are riskier than larger particles because they penetrate blood vessel walls more easily. That means that we may recommend lower levels of small-particle LDL and higher levels of large-particle LDL.

So how do you reduce your cholesterol level? A low cholesterol diet that includes whole grains, fruits and vegetables can help some patients reduce their LDL to safe levels. And some of my patients have tried herbal remedies such as garlic and niacin. But many patients need prescription medicine, especially those with diabetes or a history of heart disease. We use two classes of medicine to control cholesterol: Statins reduce the amount of cholesterol produced by the liver and resins prevent absorption of cholesterol by the digestive system.

High cholesterol is the one risk factor for heart disease that doctors can fix by writing a prescription. But I worry sometimes that in our eagerness to control cholesterol, we lose sight of the other equally significant risk factors for heart disease. The others, such as smoking and obesity, are much harder to manage – and often more frustrating for primary care doctors like me. It’s easier to write that prescription than to work with a patient for months, even years, on a weight loss or smoking cessation program.

You know the numbers by now. We recommend an LDL level of 130 or lower in healthy adults and 100 or lower in adults with diabetes or a history of heart disease. But there’s more to medicine than numbers. So here’s what I ask my patients. Do you want to quit smoking? Have you tried reducing the amount of red meat and cheese in your diet? Do you want to try exercising? And what do you want to do about your cholesterol?

It’s important to take cholesterol seriously. But cholesterol is not the disease. It’s heart disease, stroke and vascular disease that we’re trying to prevent, and cholesterol is one part of that puzzle.

Dr. Richard Lord is an associate professor in the Department of Family and Community Medicine at Wake Forest Baptist Health.

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Last Updated: 01-06-2014
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