When Dr. James Cleeman joined the U.S. Public Health Service in 1983, about 35 percent of Americans were having their cholesterol checked regularly. The last time a national survey was conducted in 1995, the statistic had increased to 75 percent.
That’s a start, Cleeman said. Now the job is to persuade people to become more sophisticated about blood tests for cholesterol and related substances, such as triglycerides–and then make the lifestyle changes of better diet and more physical activity if readings are too high. Although total cholesterol (above 200 signals higher risk for heart disease and stroke) once was a magic number, it turns out that “bad” cholesterol (LDL, or low-density lipoprotein) is the key indicator.
“We now know that lowering LDL cholesterol is definitely helpful in preventing coronary heart disease and stroke,” said Cleeman, who has been coordinator of the National Cholesterol Education Program since it was established in 1985. “Lots of good things happen when you lower LDL.”
Mostly what happens is the arteries stay clear of the plaque that forms from too much LDL in the bloodstream. You can lower LDL by eating less saturated fat, found in meats, dairy products and processed foods with coconut or palm oils. Saturated fat slows down the effectiveness of the liver to eliminate LDL from the blood. Keeping LDL to less than 100 (milligrams per deciliter of blood) is recommended for optimal health.
Yet it has been debated that lower LDL and total cholesterol could increase the risk for certain types of cancer and even suicidal depression, if levels become abnormally low. The argument is that cholesterol performs many important tasks in the body, including making essential hormones and building cell walls. HDL (women should be at 55 and above for optimal health, men at 45 and above) actually whisks plaque from blood vessels.
Cleeman said the debate is lopsided.
“A whole series of clinical trials show that lowering LDL significantly reduces risk for heart attacks and deaths without any downside,” he said.
A federal advisory panel has closely watched the trials. By late May, the panel will issue a new set of guidelines for screening and treating cholesterol levels. The buzz is that the guidelines will result in more cholesterol-lowering drugs prescribed for people with active coronary disease (to quickly reduce LDL to 100 or less). Likewise for otherwise healthy individuals with high LDL readings above 130 (especially if a person has other risk factors, such as being male, 45 or older, with high blood pressure, a family history of heart trouble, diabetes or a history of smoking).
One big reason is drugs, especially a class known as statins, which have been wildly successful in trials. They dropped LDL by 20 percent to 30 percent with minimal side effects. Some trials were stopped early because researchers didn’t want to deprive control group members of the benefits. There also is a movement to persuade the U.S. Food and Drug Administration to make statins more available to an artery-clogged American public by reclassifying them as over-the-counter.
“Statins are remarkably safe and effective drugs, but people need to remember nothing is risk free,” Cleeman said. “The side effects of muscle fatigue and raised liver enzymes are rare, but millions more people taking these drugs will translate to trouble for some patients.”
Cost is another hangup. The drugs are still quite expensive, at about $1.50 to $4 for a daily dose.
“The government needs to do something about the price of all cholesterol drugs,” said Dr. Edward Winslow, a cardiologist at Northwestern University Medical School.
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Winslow said that about 60 percent of his patients request cholesterol screenings and that most of those folks also know enough to discuss LDL and HDL. But don’t consider him satisfied.
“What I see is not enough people reacting to their elevated cholesterol readings,” said Winslow, who is medical director emeritus of the Chicago Marathon. “People aren’t making the lifestyle changes. Of the people with heart disease who should be at LDL levels of 100 or less, I would say only 15 to 20 percent of them have a level anywhere near 100.”
Winslow works with a nutritionist, who helps about a third of drug-eligible patients reduce cholesterol enough through dietary changes (less saturated fat; more fiber in fruits, vegetables and grains) to get them off medication.
For his part, Cleeman said, we will all be hearing a lot about statins and other cholesterol drugs come May–plus some new wrinkles in the numbers for LDL, HDL and triglycerides–but he doesn’t want anybody to get the wrong message.
“When we started educating people about cholesterol 15 years ago, we focused on diet, physical activity and controlling weight,” Cleeman explained. “A cholesterol-lowering regimen still doesn’t start with drugs.”
Oops, another magic pill gone poof.