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Q: How can I lower my cholesterol?Todd Christie, BSPA, MPAS, PA-CTodd Christie is a physician assistant working with Brian Schwartz, MD, FACC, FSCAI, an interventional cardiologist in Dayton, Ohio. The author has indicated no relationships to disclose relating to the content of this article.Seventeen percent of adult Americans have hyperlipidemia, a major risk factor for heart disease. Diet and exercise can help to bring this risk factor under control, with the help of cholesterol-lowering medication for patients who need it. DIET AND EXERCISE ESSENTIALSThe Adult Treatment Panel III dietary guidelines, which can lower LDL cholesterol (LDL-C) levels by 3% to 8%, percent include • Limiting saturated fat intake to less than 7% of total daily calories • Decreasing dietary cholesterol to less than 200 mg/d.1 In general, increasing the amount of fresh fruits and vegetables, 100% whole grains, low-fat/fat-free dairy products, and soy foods in the diet can help to lower cholesterol levels. So can increasing the amount of soluble fiber. After appropriate risk stratification, sedentary patients and those with other coronary risk factors or symptoms should be advised to begin exercising for 30 to 60 minutes most days each week. Good cardiovascular exercises include cycling outdoors or on an exercise bike, fast walking on a treadmill or outdoors, jogging, using an elliptical or stepper machine, swimming, water walking, and water aerobics. The American Society for Clinical Nutrition reported on a compelling study that included a small number of patients with hyperlipidemia who followed a “portfolio” diet high in plant sterols, almonds, and soluble fiber.2 The patients’ LDL-C concentrations decreased by 8.5%, 33.3%, and 29.6% after 4 weeks on the control, statin, and portfolio diets, respectively. The effectiveness of any cholesterol-lowering strategy should be evaluated 6 to 8 weeks after it has been initiated. Tests should include a fasting lipid panel, along with AST and ALT levels if the patient takes a cholesterol medication. These tests should be ordered after the patient has begun a new diet or exercise program, added medication, or adjusted medication dosage. CHOLESTEROL-LOWERING DIETARY RECOMMENDATIONS• One-half cup of Kellogg’s All-Bran Bran Buds cereal contains 5 g of soluble fiber; eating this can lower LDL-C levels by 5%. • Adding soy-containing foods or green soy beans (edamame) to the diet. • One handful of almonds (70 g) daily can decrease LDL-C by 8%.3 LIPID GOALSCholesterol targets based on current data include the following: • For males younger than 45 years and females younger than 55 years without risk factors for coronary artery disease (CAD), the LDL-C level should be less than 130 mg/dL. • If patients have only one risk factor for CAD, the LDL-C level should be less than 100 mg/dL. • The target LDL-C level for patients with diabetes or CAD, a history of ischemic stroke, two or more risk factors for CAD, or peripheral vascular disease is less than 70 mg/dL. Diabetic patients benefit from statin therapy regardless of their LDL-C level.4 • If the patient’s LDL-C level is at least 50% higher than the target level, start therapy with atorvastatin (Lipitor) or rosuvastatin (Crestor). • Once the LDL-C target is reached, treatment should focus on reducing triglycerides to less than 150 mg/dL. • If HDL cholesterol (HDL-C) levels are less than 40 mg/dL in men or less than 50 mg/dL in women, therapeutic lifestyle changes should be maximized and adding an agent like niacin (Advicor, Niacor, Niaspan) should be considered. Niacin has been demonstrated to raise HDL-C levels by 30%. • For hypertriglyceridemia, the new prescription omega-3-acid ethyl esters (Lovaza) may be considered. The FDA approved this agent for patients with triglyceride levels higher than 500 mg/dL. Fenofibrate is also very effective for hypertriglyceridemia and should be considered even when the patient already takes a statin.5 THE BOTTOM LINEProper nutrition and physical activity have proven benefits for primary and secondary prevention of CAD. When diet and exercise fail, lipid-lowering medications should be started without delay. JAAPA For patient information on this topic, please see the next section. Katie Iverson, PA-C, MPAS, department editor REFERENCES
Q: How can I lower my cholesterol?High cholesterol is one of the main risk factors for heart disease. Nearly 1 in 5 Americans has this problem. If you are one of them, it is important to find ways to lower your cholesterol levels. CAN DIET AND EXERCISE HELP?Eating foods that contain saturated fat, trans fat, or cholesterol can raise cholesterol levels. Saturated fats come mostly from animal foods. Examples are meat, butter, and whole milk. Some vegetable oils, such as palm kernel oil, also contain trans fat. Trans fats are made when vegetable oil is hydrogenated to harden it. Trans fats are also made when oil is superheated, as with frying. Cholesterol is found in foods that come from animal sources such as egg yolks, meat, and full-fat dairy products. You should try to eat less saturated fat and less cholesterol. Instead, eat more fresh fruits, vegetables, 100% whole grains (whole wheat, whole oat), and low-fat or fat-free dairy products. It is also good to eat soy foods and soluble fiber. This is the type of fiber found in apples, berries, eggplant, and oats. After your health care provider has said you can exercise, do so for at least 30 minutes 5 days a week. Choose a type of exercise that increases your heart rate. This is called cardiovascular exercise. Options are biking, fast walking, jogging, using an elliptical or stepper machine, swimming, water walking, or water aerobics. Other exercises may work too. Ask your health care provider if you don’t know whether an exercise is a good choice. DO ANY FOODS LOWER CHOLESTEROL?Include the following foods in your diet every day:
WHAT WILL HAPPEN IF I MAKE THESE CHANGES?Table 1 shows the benefits of each change.
WHAT ABOUT FISH OIL?Fish oil contains omega-3 fatty acids. These are natural substances that your body needs. You can get them through your diet. These fatty acids are in foods such as fish and flax seed meal (and/or oil). Two forms of omega-3 fatty acids have been shown to benefit health. The EPA and DHA forms of omega-3 fatty acids are found in oily fish, such as salmon, lake trout, mackerel, tuna, and herring. Higher concentrations of EPA and DHA can be found in a new prescription omega-3 supplement designed specifically for patients with high triglyceride levels. With less concentrated, over-the-counter fish oil preparations, you may have to take 9 to 16 capsules to get the desired amount of omega-3s needed to lower triglycerides. Fish oil capsules may upset your stomach. If they do, try freezing them to prevent this. It is important to know that some types of fish may contain mercury and other pollutants from the environment. The American Heart Association warns that some people should limit the amount of certain types of fish they eat. WHAT ABOUT CHOLESTEROL MEDICINE?Some patients must take cholesterol-lowering medicine if they are not able to lower their cholesterol through diet and exercise alone. Also, patients with diabetes and certain forms of heart disease benefit from cholesterol medicine, regardless of their cholesterol level. You should get your cholesterol level checked 6 to 8 weeks after you start a new diet and exercise program, start a new cholesterol-lowering medication, or make any change in cholesterol medication. THE BOTTOM LINEA well-planned diet and daily exercise are the foundation to living a longer, healthier life. If you are thinking of going on a cholesterol-lowering diet, talk to your health care provider first. This is very important when planning any changes in your diet or exercise program. You can also get informa- tion on cholesterol-lowering methods (including sample menus) from your local public library and on the Internet at www.americanheart.org. JAAPA |
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