What you must know about your cholesterol

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Many of us are in the danger zone, and we don't realize it. What to do right now

HOW'S YOUR CHOLESTEROL? Here's a guess: If you're healthy, you probably have no idea. New surveys show women tend to be clueless about their risks of heart disease, especially when it comes to managing their cholesterol. But this kind of ignorance is anything but bliss. The reason: The artery clogging that makes heart disease the number-one killer of women late in life begins much earlier — in your 20s, 30s, and 40s — and that's when your cholesterol numbers may be sounding alarms. So, are you ready to start paying attention? Here, the things all women need to know now.

Inside job: High cholesterol can quietly lead to heart disease by clogging your arteries.

1 High cholesterol is surprisingly common.
Researchers with the Framingham Heart Study recently delivered a nasty surprise: Nearly a quarter of women in the study who are in their early 30s have borderline-high levels of bad cholesterol, as do more than a third in their early 40s and more than half in their early 50s. A third of women in all three age groups have low levels of good cholesterol.

Bad cholesterol, also known as low-density lipoprotein (LDL), contributes to heart disease by laying down artery-clogging plaque; good cholesterol, or high-density lipoprotein (HDL), helps clear it away. "The double whammy of high LDL and low HDL is particularly dangerous," says Framingham researcher Vasan Ramachandran, MD, of the Boston University School of Medicine.

2 Your doctor may miss the problem.
Though women are better than men about seeing a doctor regularly, the care they receive isn't as good when it comes to preventing and treating cardiovascular disease, according to new studies. "Perhaps doctors still haven't gotten the message that women need to control cholesterol," says Chloe Bird, PhD, author of one of these studies and a senior sociologist at the nonprofit RAND Corporation. Bird found that doctors are less likely to monitor and control cholesterol in women than in men, even when the women are at superhigh risk of heart attack.

Part of the problem, she says, may be that many women see only a gynecologist. This isn't to say that OBGYNs can't be good primary care doctors, but you have to make sure the doc is willing to monitor your heart health, especially if you already have diabetes or a heart issue. That means she should order cholesterol checks as part of your regular blood work and discuss the results with you. What does "regular" mean? See "How Often Do I Need a Checkup?" page 77.

3 Your numbers may trick you.
Many people misunderstand the roles of so-called good and bad cholesterols, according to cardiologist and lipidologist Pamela Morris, MD, of the Medical University of South Carolina in Charleston. "What we've learned is that HDL and LDL are independent predictors of a woman's heart attack risk," she explains. "We see women with high HDLs having heart attacks when their LDL is also high, and we also see heart attacks in women with very low LDL but also low HDL."

What that means to you: It's important to keep track of both. A woman wants to keep her HDL above 60 (the level at which HDL helps prevent disease) and her LDL below 100. If your HDL drops below 50 or LDL rises above 160, you need to take immediate action. That may include an LDL-lowering drug such as a statin, and it definitely includes a commitment to a heart-healthy diet and lifestyle.

Danger zone: The walls of a healthy artery (left) can become obstructed by sticky bad cholesterol over time (middle), eventually leading to life-threatening buildup of plaque (right).

4 You may need an "inflammation" test.
The math used to estimate your heart disease risk is a little misleading. If your LDL rises above the danger line of 160 or your HDL drops below 50, the math says you have an elevated risk of a heart attack within 10 years. But that warning may actually underestimate your risks beyond 10 years, Morris says. So when she has a female patient with cholesterol numbers in the intermediate range — LDL above 130 or HDL under 60 — she often takes a close look at the woman's whole-body inflammation level.

You can't see this kind of inflammation, but it's actually an independent measure of heart attack risk. You measure it by adding a test for high-sensitivity C-reactive protein (hs-CRP) to the usual cholesterol blood work. CRP, essentially a body chemical, usually rises anytime your body becomes inflamed. And since artery clogging is associated with inflammation, high CRP is viewed as a marker for clogged arteries. That means your C-reactive protein levels may help you and your doctor decide how aggressively you need to control borderline-high-cholesterol levels with drugs, diet, and exercise.

5 These foods are your best friends.
Certain classes of food chemicals can actively and powerfully lower a person's bad cholesterol. Two — soluble fiber and phytosterols — have so much science behind them that they've become part of standard medical prescriptions for treating high cholesterol. But dietitian Janet Brill, PhD, RD, author of Cholesterol Down, also recommends regularly eating almonds, ground flaxseed, apples, soy protein, and olive oil. Preliminary research suggests they all have cholesterol-lowering powers. "Each one works in a slightly different way," Brill says. "So together, you get a synergy that can dramatically lower cholesterol."

Almonds and olive oil are high in monounsaturated fats, which are thought to blend with LDL molecules in a way that speeds LDL's clearance from the blood by the liver. Flax is high in both soluble fiber, which lowers LDL by absorbing cholesterol from both food and bile inside the intestines, and omega-3 fatty acids, which studies show have anti-inflammatory effects. Other foods especially high in soluble fiber include oat bran, oatmeal, and apples. (Soluble fiber is different from insoluble fiber, the kind found in whole-grain bread and bran cereal. That's good for you, too, but it won't affect your cholesterol.) Soy may mimic natural estrogens in their LDL-clearing effects. Phytosterols are the plant version of animal sterols (a.k.a. cholesterol) and lower LDL by competing with it for absorption into the body. They're found in supplements or phytosterol-enhanced margarine such as Benecol.

Go Mediterranean: Olive oil is high in monounsaturated fats, the kind that may help your body rid itself of bad cholesterol.

You don't need any of these foods if your LDL is low, but experts still recommend them for everyone. What about steak, eggs, and cheese? They sure won't help your cholesterol, because they all contain a lot of it. But it's more important to focus on foods that lower your numbers rather than simply avoiding the bad stuff, experts say.

6 Good cholesterol may have a bad side.
The higher your HDL, the better, right? That's been the current thinking, due to HDL's protective effect. But here's a surprise you may have read about in some news reports: Studies are showing that HDL may actually have harmful proteins capable of boosting heart disease risks. A test to determine if your HDL has the harmful proteins may be available in a few years. In the meantime, if your HDL is lower than 60, it's still OK to raise it a little as long as you don't go overboard. How? Try getting a lot of omega-3s from fish or fish oil, exercising regularly, controlling your weight, and avoiding smoking.

7 Your heart loves long walks.
Walking 10 miles a week brings lasting improvements in your heart health, according to researchers at Duke University Medical Center. The funny thing is, if you jog those 10 miles, you won't get quite as much benefit. "Duration appears to be key," says Duke's Cris Slentz, PhD, an exercise physiologist. "Jogging or walking 10 miles both burned around 1,200 calories, but in our studies, one took about two hours and the other, three."

Longer stints of exercise, even moderate exercise, may burn more belly fat — the little rolls of skin near your navel and the fat deep inside your abdomen. The latter is linked to metabolic syndrome, a condition associated with a host of cardiovascular risk factors including low HDL, high blood pressure, and high triglycerides (a kind of blood fat that contributes to heart disease).

Walk therapy: It may beat running for heart health.

Should you aim for weight loss as well as long walks? If you're overweight, absolutely. But understand that shedding a few pounds will make only a small dent in your cholesterol. Canadian researchers recently found that overweight women who lost about 25 pounds — no easy task — saw their LDL drop about 10 percent and their HDL rise by the same amount.

My battle with high cholesterol Yes to flax, no to fried food
A former Marine officer and marathoner who always took pride in eating well and remaining fit and trim, Himes watched in surprise as her cholesterol levels rose from bad to worse after she left the military in 2005. Last March her overall cholesterol peaked at 226, and more than half was bad, LDL, cholesterol. What happened? She slacked off From regular exercise and started eating more fried food. But everything changed when Himes returned to lifting weights and running and began adding cholesterol-lowering foods such as beans, flaxseed, oatmeal, psyllium-powder supplements (a soluble fiber), and soy protein to her diet. "I was secretly hoping to get under 200," she says. She did much better, bringing her total down to 165 and her LDL down to 97 in just five months!

Linda Ferrell Himes Age 35 Virginia Beach, Virginia

My battle with high cholesterol Sometimes, it's a family issue
Russo discovered she had high cholesterol at age 30, during her first pregnancy. "It came out as part of my prenatal blood work, but I kept putting off taking care of it." Then three years later, her 59-year-old mother had a heart attack. "That was a real wake-up call," Russo says. "We didn't even know heart disease ran on her side of the family." Heart disease and high cholesterol often run in families. As a result, says dietitian Janet Brill, PhD, RD, "many people give up on a healthy diet with an attitude of 'it's in my genes.' But that's hogwash."

Russo got that message loud and clear when her cholesterol rose into the stratosphere — her total was approaching 350. After three months of oatmeal for breakfast and walk-aerobic tapes, her numbers dropped into the upper 200s, still dangerously high. A low-dose statin brought them down to 189 (and brought her HDL up). Now her levels are below high-risk but still less than stellar. "I'm still working on it," Russo reports. "And now that I'm watching my sister's kids along with my own three, I'm getting more exercise than ever just chasing them around."

Mary Anne Russo Age 37 Mahopac, New York

How often do I need a checkup?
Starting at age 19 and continuing until menopause, a cholesterol test once every five years is plenty — as long as your numbers fall in the healthy range:

HDL > 60
LDL < 100
Total cholesterol (HDL plus LDL) < 200.
But any time your numbers stray into unhealthy territory (and during and after menopause, when heart disease risk rises), get tested annually and work out an action plan with your doctor.

My battle with high cholesterol Hit the treadmill … and hope
Diane Grasha Age 53 Nashville, Tennessee

Grasha found out in 2006 that she had high (107) good, or HDL, and high (141) bad, LDL, cholesterol. She hasn't hit menopause and isn't overweight, but she's close to the age when heart disease risks rise as estrogen drops. Rather than jumping straight to a cholesterol-lowering statin drug (she was worried about their rare but serious side effects, such as muscle and liver disease), she began working with cardiologist Pamela Morris, MD, of the Medical University of South Carolina on a new diet-and-exercise plan. She bumped up her walking and treadmill work from 30 minutes three or four days a week to 30 to 45 minutes six to seven days a week, and began eating more plant sterols and soluble fiber. After nearly a year, Grasha's LDL cholesterol hasn't dropped much. "It may be time to have another discussion with Dr. Morris," she admits. A statin may be necessary. In the meantime, Grasha thinks she can make more inroads with diet and exercise.

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By Jessica Snyder Sachs

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