Look for Yourself in Cholesterol Guidelines
Question: So there’s a bunch of new cholesterol guidelines. Why should I care this time?
Answer: The guidelines, issued recently by the National Heart, Lung and Blood Institute, are more aggressive than earlier ones. The government wants to treat more people, and treat them sooner to prevent heart disease and its related deaths (and costs). So if you didn’t qualify for cholesterol-lowering treatment under the old recommendations, you may qualify now. The new guidelines can be tailored to your particular collection of risk factors. To figure out where you fall, you’ll have to do two things: (1) determine which major risk factors you have; and (2) compute your risk of developing heart disease using a Web site or a chart.
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Q: Yeesh. Where do I start?
A: First, roll up your sleeve: You’ll need to get a blood test--and it has to be the “fasting” kind, where you haven’t eaten anything for 12 hours before the blood is drawn. (Sorry, health-fair finger-pricks and home tests don’t count.) The results will give you a bunch of numbers, including total cholesterol; low-density lipoprotein (LDL, the most dangerous type); high-density lipoprotein (HDL, the “good” stuff); and triglycerides (another dangerous kind of blood fat). You also need to find out your blood pressure and whether you have diabetes.
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Q: Then what?
A: Before you get to the numbers, figure out if you’re an automatic “highest risk.” The new guidelines bump anyone with Type 2 diabetes into the highest-risk group, meaning your risk is the same as if you already had a heart attack. So get screened for Type 2--your doctor does that too.
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Q: OK, so if I don’t have diabetes, I’m fine?
A: Not so fast. Other newly proclaimed high-riskers include all people who have had bypass surgery or angioplasty; suffered a stroke; or been told that they have unstable angina, blockages in their carotid arteries or peripheral vascular disease.
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Q: OK, if I don’t have diabetes or any of those things, I’ve got nothing to worry about?
A: Sorry again. Now count how many of the following risk factors you have, based partly on the information above that we urged you to get from your doctor:
1. Cigarette smoking.
2. Blood pressure greater than 140/90 or the need to take medicine to lower blood pressure.
3. HDL lower than 40 milligrams.
4. Family history of heart disease (meaning that your father or brothers got heart disease before age 55 or that your mother or sisters got it before age 65).
5. Age (men older than 45 years; women older than 55).
If you have one or fewer risk factors, you still may be a candidate for therapy if your LDL is high enough. But if you’ve got two or more risk factors, go to the National Heart, Lung and Blood Institute Web site (//hin.nhlbi.nih.gov/atpiii/calculator.asp). Plug in your information, hit the calculate button and find out your risk of developing heart disease during the next 10 years.
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Q: What if I don’t have access to the Web?
A: Head to the nearest public library; nearly all libraries provide Web access. (Ask the librarian, if you need help.) Or if you just can’t bear to deal with electronics, send for a risk computation chart by writing to the NHLBI Information Center, P.O. Box 30105, Bethesda, MD 20824-0105. Or call (301) 592-8573. Ask for “High Blood Cholesterol: What You Need to Know.” Single copies of the chart are free. Or you can talk to your doctor--assuming he or she is up on all of this new material--and perform a risk assessment together.
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Q: OK, I did the Web thing. Now what?
A: It depends on the number you emerged with, which describes your percentage risk of developing heart disease over the next 10 years.
* A score of 20% or greater puts you in the highest risk category--the same as if you have diabetes or already had a heart attack. Odds are that you will be going directly to cholesterol-lowering drugs. But you don’t get a lifestyle pass just because you’re taking drugs: You still have to do the diet and exercise thing.
The desirable LDL level is 100 milligrams or less. If it’s 100 to 129, diet and exercise changes are prescribed right away, and drugs are an option. If your LDL is greater than 130 milligrams, cholesterol-lowering drugs are recommended immediately along with lifestyle changes.
* Two or more risk factors, and a risk of 10% to 20% (next highest risk): If your LDL is less than 130, you’re still in the desirable range. Go ahead and live prudently. But if you’re above 130, it’s time for “therapeutic lifestyle changes”--in other words, the old diet and exercise routine (with a few new tweaks, described below). Try this for three months. If it’s still 130 or above, you will likely get drug treatment.
* Two or more risk factors and less than 10% risk (moderate risk): If your LDL is under 130, you’re good to go. When it hits 131, you too become a candidate for immediate diet and exercise changes. If it’s 160 or more, jump onto diet and exercise changes for three months, and if that doesn’t lower your LDL, get ready to fill your prescription for cholesterol-lowering drugs--in addition to sticking with your diet and exercise changes.
* One or fewer risk factors and less than 10% risk (low-to-moderate risk): Give yourself a star--but you’re not home free unless your LDL is less than 160 milligrams. If it’s greater than 160, you need to make significant diet and exercise changes. If that fails to bring your number down after six weeks, add stanols to your diet (see below), increase fiber and work with a dietitian. If LDL still doesn’t drop within 12 weeks, it’s probably drug time. And it’s likely drug time if your LDL tops 190--even with one or fewer risk factors.
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Q: I know all about the low-fat, heart-healthy diet; I’ve avoided it for years. Is there anything new?
A: Yes, it’s time to meet your new friends--stanol esters and soluble fiber. Stanol esters are plant forms of cholesterol; they’re found in some margarines and other products with names such as Take Control and Benecol. Science shows they can help lower heart disease risk. Eat up to 2 grams per day. Soluble fiber--such as oatmeal--also can help. Aim for up to 25 grams per day.
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Q: Is that all?
A: Of course not. Instead of the old standard of holding saturated fats (fatty meats, some oils, lots of baked goods) to 10% of total calories, the new diet calls for eating no more than 7% of your daily calories as saturated fat and less than 200 milligrams of dietary cholesterol. Plus, now you have to include artery-clogging trans-fatty acids in that total. You’ll find trans in crackers, baked goods, most French fries; maddeningly, they are not disclosed on food labels.
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Q: Are we done?
A: No. You also have to worry about metabolic syndrome. At least one in every four American adults has this, and it also rockets your risk higher. To qualify, you need three of the following: abdominal obesity (for men that means a waist of 40 inches or larger; for women, 35 inches or more); triglycerides higher than 160 milligrams; HDL less than 40; blood pressure higher than 130/85 millimeters and fasting blood sugar greater than 110 milligrams.
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Q: Can I go now?
A: Only if you promise to be careful.
