Your Number’s Up: How to Bring Down Your Cholesterol

What's your number? Cholesterol number, that is, and how hard do you have to work to bring it down? Andrea Becker, MD, Lankenau Hospital cardiologist, shares the latest research on alternatives to cholesterol-lowering drugs. Do they really work?

Exactly what is cholesterol?
Cholesterol is a natural, waxy substance found in your bloodstream and all your body's cells. Among other functions, it produces cell membranes, some hormones and acids, and vitamin D.

Why should I be concerned about cholesterol?
Our body makes all the cholesterol it needs, and that's where its widely known connection with heart disease occurs; you don't need to get any more cholesterol from food. So the more cholesterol-raising foods you eat -- and the primary culprits are saturated fat, cholesterol, and trans fat -- the more you raise your risk of cardiovascular disease, heart attack, and stroke. Saturated fat is found mostly in animal products, and cholesterol is found only in animal products. Trans fat is found in processed foods.

What are healthy cholesterol levels?
An estimated 65 million American adults have elevated cholesterol levels. For low-risk patients, the American Heart Association recommends these cholesterol levels:

• Total cholesterol-less than 200 mg/dL.
• LDL cholesterol-less than 100 mg/dL.
• HDL cholesterol-greater than 40 mg/dL.
• Cholesterol ratio (ratio of total cholesterol to HDL cholesterol)-below 5 to 1 with an optimal ratio of 3.5 to 1.
• Triglycerides-less than 150 mg/dL.

What do the terms LDL, HDL, and triglyceride mean?
Cholesterol is carried through the blood stream to and from cells by lipoproteins, specifically low-density lipoproteins (LDL) and high-density lipoproteins (HDL).

• LDL carry cholesterol from the liver to parts of your body and can build up in your arteries, clogging them with plaque. It is called the "bad" cholesterol.
• HDL, the "good" cholesterol, carry cholesterol from the tissues back to the liver, where it is removed from the body.
• Triglyceride is a type of fat that provides the body with energy. Like cholesterol, circulates in the blood with the help of lipoproteins.

What if my cholesterol levels remain high despite changes in my diet and lifestyle?
You'll always need to eat well, maintain a proper weight, and exercise for your overall health. But if these measures aren't enough to reach your desired cholesterol levels, we can prescribe medications such as aspirin or statins. Studies indicate that each of these medications is effective in the prevention of heart attacks and other cardiovascular events. What's more, other therapies, such as red yeast rice, plant stanols, and omega-3 fatty acids, are being looked at as alternatives or as additions to statins.

What are statins?
Introduced in 1987, statins -- powerful cholesterol-lowering drugs -- marked a milestone in the fight against heart disease. Statins block an enzyme that causes the liver to produce cholesterol, reduce inflammation, and can prevent plaque from rupturing and potentially blocking your arteries, leading to a heart attack.

Statins are prescribed for people with established cardiovascular disease and those at high risk, even without known cardiovascular disease. Now, it's believed that people at moderate risk of heart disease can also benefit from statins. Published in the Archives of Internal Medicine, an analysis of studies that included more than 48,000 people found a 29 percent cent lower incidence of heart attack and a 14 percent reduction in strokes among people who took a statin rather than a placebo over an average of 4.3 years.

Statins are not without risks, including rare liver toxicity. You may also experience muscle pain and intestinal upset. If you take statins, your physician will monitor your liver function.

What's the evidence for omega-3 fatty acids in the prevention of cardiovascular disease?
Numerous studies detailed in the American Heart Association's journal, Circulation, support the heart protective effects of omega-3 fatty acids, commonly known as fish oil. In addition, we know that cultures following the Mediterranean Diet, which is rich in fish consumption, have a low incidence of cardiovascular disease.

Two government reports released in 2006 concluded that fish may be the single most important food to eat for health, and that the benefits for the vast majority of consumers far outweigh the risk of mercury found in certain species. (Separate recommendations have been made for fish consumption by pregnant women and children.)

In the government studies, the heart-protective benefits started with 250 grams a day of omega-3 fatty acids (the usual dose for cardiac protection is 1 gram of omega-3 fatty acids) which you can get in just one 6-ounce serving a week of an oily fish. Researchers think omega-3 fatty acids retard plaque growth and inflammation, keep platelets from forming dangerous clots, and help reduce the risk of LDL and sudden cardiac death. Studies on fish oil supplements also support the idea that fish oils have beneficial effects on the heart's electrical system.

How much fish should you consume?
The American Heart Association recommends at least two servings per week, particularly from fatty fish, prepared the proper way-baked or broiled, but not fried.

I've been hearing a lot about red yeast rice. What is it?
Red yeast rice, a staple in some Asian countries since 800 A.D., is basically the product of red yeast grown on rice. For centuries, it has been used to improve blood circulation. Red yeast rice contains compounds known as monacolins, one of which, monacolin K, inhibits the liver's production of cholesterol.

Red yeast rice is sold over-the-counter as a natural cholesterol-lowering agent. Lovastatin, in Merck's drug Mevacor®, behaves similarly to monacolin K. The amount of monacolin K in red yeast rice, however, is very small when compared to the lovastatin in the prescription drug. If you take red yeast rice, however, blood tests should still be performed as it is a mild statin with the same side effects.

There have been only a handful of studies in the West on the effectiveness of red yeast rice, which report decreases in total cholesterol, LDL cholesterol, and triglycerides, as well as anti-inflammatory effects. There is a dispute as to whether red yeast rice should be classified as a drug (and regulated) or remain a dietary supplement. It's wise to read the labels carefully for its ingredients.