Leo Galland, MD
Foundation for Integrated Medicine
Andrew L. Rubman, ND
I.W. Lane College of Integrative Medicine
While it is comforting to feel that current medical thinking is based on scientific fact -- the real fact is that it is just the latest information available. Case in point is the upheaval surrounding the role of cholesterol as risk factor for heart disease. For a long time now, medical science has talked about the virtues of having low total cholesterol and, more importantly, having a good ratio of HDL to LDL cholesterol. Now the news is that extremely low LDLs make a big difference and, more significantly, that "inflammation" may be an even larger indicator of risk than cholesterol levels.
On May 3 we talked about the Lipitor study that found low-low-low LDL cholesterol to be good. (To review this article, click here.) But there is still confusion regarding HDLs and whether belief in their benefits have gone by the wayside.
To know more about the status now, I spoke to Leo Galland, MD, director of the Foundation for Integrated Medicine in New York City. There is good reason that we are all very confused. According to Dr. Galland, the question of the importance of LDL (bad cholesterol) vs. HDL (good cholesterol) is not an either-or proposition. Yes, LDL levels are very significant, but HDL levels also continue to be an important independent risk factor for heart disease, along with other factors.
THEN AND NOW
In recent years, experts believed that a high HDL offset a high LDL, and that it was the ratio of HDL to LDL that was most significant.
More recently, two studies showed that very low levels of LDL (as low as 62) offer significant protection not only against plaque growth in the arteries but also against heart attack. This finding suggests that treating elevated LDL is of paramount importance, whether or not HDL is high. Daily Health News contributing editor Andrew L. Rubman, ND, reminds us, however, that this was not a properly "controlled" study -- it only looked at the impact of two statin drugs on LDL reduction in people who already had a history of heart conditions. There was no control group without heart disease, nor did the study look at the role of HDL or the role of plaque and coronary artery narrowing on results.
HDL AND HEART DISEASE
While there is increasing doubt that high HDL can completely counteract high LDL, there is no question that a low HDL increases the risk for atherosclerosis (accumulation of fatty deposits on artery walls) and cardiovascular disease. Particularly dangerous combinations are...
- Low HDL and elevated triglycerides (fat-carrying particles).
- High LDL and low HDL.
What can you do to boost low levels of HDL? Primarily, exercise and control your weight management, says Dr. Galland. Smokers who quit can raise your HDL by up to 20%. For those with no history of alcoholic liver disease, many researchers recommend a glass of red wine each day (two for men).
LOOKING BEYOND CHOLESTEROL -- HEART DISEASE IS MULTIFACETED
No single factor, such as high LDL, causes heart disease. Nor does any one factor, such as high HDL, prevent you from developing it. Since only half of all people who have heart attacks have high LDL cholesterol, you have to look at the entire picture -- family history, blood pressure, weight, level of exercise, diet, smoking status and coexisting conditions, particularly diabetes.
Other important factors to consider are C-reactive protein (CRP), homocysteine and insulin resistance.
- CRP is a protein produced in the liver and is a significant marker for inflammation, which is increasingly seen as playing a major role in heart disease. CRP can be measured with a standard blood test available through any clinical laboratory and should be screened for in tests for cardiac risk. CRP testing is currently recommended for those with heart disease or risk factors for heart disease.
- Elevated homocysteine is also associated with a higher risk for coronary artery disease. Evidence suggests that a buildup of this amino acid damages the inner lining of arteries, promotes blood clots and encourages atherosclerosis. Homocysteine also is tested for in a cardiac risk panel.
- Insulin resistance: Insulin is a hormone that normally helps your body metabolize sugar. However, sometimes tissues in the body stop responding to insulin. In this condition, which is known as insulin resistance, your blood sugar level is not quite high enough to constitute diabetes... but it is higher than normal, and the normal control over blood sugar exerted by insulin is dampened. A recent study showed insulin resistance to be a more significant risk factor for heart attack than either HDL cholesterol or triglycerides.
HOW TO LOWER YOUR RISK
The more we learn about heart disease and its causes, the more steps you can take to lower your risk. Heart-protective strategies include...
- Get moving. Regular exercise can help you raise HDL and lower LDL, triglycerides and CRP.
- Maintain a healthy weight. Being overweight causes HDL to fall and LDL and CRP to rise.
- Dr. Galland recommends a diet rich in natural disease-fighting antioxidants from fruits, vegetables, nuts and seeds. Also, avoid foods that are high in saturated fat, trans fats and cholesterol, such as higher-fat beef products, fried foods, processed foods and full-fat dairy products. These raise your bad LDL cholesterol, and trans fats also can lower your good HDL.
- Generally, Dr. Galland does not recommend treating low HDL levels with drugs. However, if you also have high LDL and high triglycerides, and diet and exercise are not sufficient to control them, then statins may be appropriate. Watch out for side effects, such as changes in liver function (as measured by your health-care professional with regular blood tests). Muscle weakness often can be a problem too.
- According to Dr. Galland, potentially helpful supplements include folic acid (your best bet for lowering high homocysteine levels), fish oils (supplements that supply 1,500 mg of DHA each day), chromium, magnesium, green tea flavonoids and red yeast rice (Kay’s Note: Red yeast rice is not SCD legal). A word of caution with red yeast rice: It acts as a natural statin, so you should be on the lookout for side effects just as with statin drugs.
The bottom line? The cholesterol question will take years to sort itself out conclusively. However, what you can do to reduce your risk factors has remained consistent -- making smart lifestyle choices. Adhering to a healthy diet and regular exercise program and quitting smoking, too, can significantly improve your odds. If these prove insufficient and your health-care provider prescribes statins, be sure that you weigh the consequences of the decision.
Statins have been associated with serious side effects, including birth defects. They are specifically not recommended for pregnant or breast-feeding women.
Stay tuned for a discussion of Inflammation and it's impact on heart disease in the June 10th, 2004 issue of DHN.
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