What your heart wishes you knew about cholesterol

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I married a very smart man. But even smarties can be dumb when it comes to cholesterol numbers. For instance: What's your cholesterol? I asked my human encyclopedia. It's 228, he replied. I frowned: That's high. No, it's borderline high, he argued. As if borders were safe. I said: More people get heart attacks around 225 than with any other numbers. I'd like you to get a full lipid profile for my anniversary present. I need to know how much good fat you have in there with the bad.

Cholesterol is serious business. Before you say, yeah, been there, know that, and flip the page, Listen! This is the sound of a myth being broken: The famous, total cholesterol number of 200 that most people consider safe ain't necessarily so. That number won't protect you. You're not really safe until you hit 150 or below.

"If your cholesterol is below 150, you're home free," says Prevention advisor William Castelli, MD, who headed the landmark Framingham (MA) Heart Study for 16 years. "Virtually no one gets a heart attack at that level. But twice as many people in our country get heart attacks with cholesterols between 150 and 200 as those with cholesterols over 300. For instance, 35% of the people in the Framingham Study who had heart attacks had cholesterol between 150 and 200."

Don't panic if your 198 cholesterol suddenly looks less than peachy. It may be fine. We'll tell you how to find out, and how to make it fine if need be. Read on.

The escalator of fat
Atherosclerosis--the buildup of plaque in the arteries--starts to accelerate when your cholesterol gets over 150, explains John LaRosa, MD, chancellor of Tulane University Medical Center, New Orleans.

"Think of cholesterol numbers like rungs on a ladder," says Peter Wilson, MD, current director of laboratories at the Framingham Heart Study. "At any level over 150, you can slip and fall. And the higher you go, the greater the risk. But you can stop the ascent before you get up too high."

So why does the number 200 stick to our brains like plaque to an artery?

"The problem is we've confused average cholesterol with normal cholesterol," explains Dr. LaRosa. Among Americans today, the average total cholesterol hovers around 215. But being average isn't good enough when it comes to protecting your heart. To really reduce the risk of heart attacks, you need a safe cholesterol number--one that is under 150.

"Most of the people who live on this earth--in China, Asia, Latin America, Africa, outside the big cities--don't get heart disease. It's not easy to get. And they can't get it because their cholesterol is below 150. Bring them to this country, though, feed them our meals, and they will," says Dr. Castelli.

Recalculate
If you felt comfortable because your cholesterol is 198 or 189, don't get upset: Get your HDL (high-density lipoprotein--the "good" cholesterol) number instead. (We'll tell you how in just a bit.). Then use it to find your total-to-HDL ratio. You do that by dividing your total cholesterol number by your HDL number.

If your ratio is under 4, you can relax. You're one of the people who really are safe from heart attacks. In fact, some folks with cholesterol over 200 may not have that great a risk, because a high HDL can offer protection. I'll relax if my husband's ratio is under 4, for instance, because that means he has enough HDL to collar the bad low-density lipoproteins (LDLs) and frog-march them to the liver for disposal--despite a 228 number. (But, notes Dr. LaRosa, this HDL protection only goes so far. If your total cholesterol is over 300, it's too high.)

"The cholesterol number alone is 90% useless," confirms Dr. Castelli. "That's why I delivered a letter to American physicians last year in Prevention (November 1996) disputing the American College of Physicians' cholesterol guidelines.

These guidelines limit screening to just the total cholesterol number, except for those who already have heart disease or are at high risk for it. They created a ruckus when they were released last year, because many doctors, including members of the American Heart Association, know that following these guidelines may cause a heap of heart disease to be missed in those folks with 150 to 200 cholesterols. Those are people who can go on to get heart attacks. Worse, the guidelines can fail to sound the red alert to those who could lower their dangerous ratios while coro-naries are still preventable.

Good news: Other guidelines exist, including those of the National Cholesterol Education Program (part of the National Heart, Lung, and Blood Institute), which advise doctors to test both total cholesterol and HDL. Bad news: A poll conducted by Prevention for our "Heart-to-Heart" survey (February 1997), and published in the Journal of Women's Health (April 1997) found that, even among our savvy readers, only 65% had doctors who checked cholesterol--hardly perfect. But that was better than our national poll--only 45% of the people in our tele-phone survey received any tip-off figures.

Evaluate
Don't feel too bad if you have to revise your number(s) when you thought you were safe. After all, many doctors have to revise their advice on this, too. But it's your heart. And it could be your heart attack. Coronaries are nasty beasts. They mess up work. They mess up fun. They cheat your grandchildren--of you.

But before you get scared, check the combined cholesterol picture. The favorite runner-up myth on cholesterol in America is that it's only one number. Forget the myths. The reality is as simple as one, two, three: You should know your total cholesterol, your HDL and your ratio. Here's how to find your numbers:

Make a date for a profile Tell your doctor you want to keep tabs on your cholesterol levels and ask him where you can go to get a lipid profile. (Your profile will include your total cholesterol and HDL levels.) If your insurance won't cover it, find a way to pay the $25 to $60. A new option: Call Wal-Mart and find out when a store near you will be offering its $29 lipid profiles. Those tests are accurate and they will give you the numbers you need to do the easy math for your ratio. (See "Medical-Care News," Prevention, August 1997, for more on this program.)

Get it again Dr. Wilson advises getting at least two cholesterol tests within an eight-week time frame. "There can be a 12-point variation in total cholesterol. And HDL can vary quite a lot, too." If the difference in cholesterol levels is over 30, take a third test, and then find the average of all three.

Make a note Whenever you take a cholesterol test--every five years if it's good, every year or more if it's bad--write down the results. "We give patients a scorecard, and they have to keep updating those numbers," says Dr. Castelli, now medical director of the Framingham Cardiovascular Institute. (You can use our scorecard from Prevention's April 1996 issue, in the article "Your Game Plan for Life.")

The two cholesterol commandments
We know you've heard it up to here about cholesterol. But it's vital. And it's one of the easiest problems to control on your own. Here's the basic strategy for lowering the stuff and preventing national hangman number one: heart disease. This time, do it.

Defat your diet "If you look at large groups of people, the overwhelming determinant of cholesterol level and cardiac risk is diet and intake of animal fat," says Dr. LaRosa. "You've just gotta get that fat off your plate. That's the key. We are designed to be plant eaters--we have flat teeth and long intestines for digesting vegetables. We're not meat eaters, like some bears. They have sharp, tearing teeth, short intestines--and cholesterols of 500--but it's all HDL. They never get atherosclerosis, because they were meant to eat meat."

A low-fat diet (Prevention recommends staying below 25% total fat, and below 20 grams in saturated fat) helps lower bad LDLs, so HDL isn't overwhelmed. A diet of this sort can lower cholesterol 5 to 15 points, or even more.

While you're eating less meat, eat more fruits and vegetables. The antioxidants in them keep LDL from sticking to the walls of your arteries. Very important.

Work it up Diet and exercise must go together, says Dr. Castelli. The beauty of the combo is that exercise raises your HDL levels while the diet lowers your LDL. And each milligram per deciliter (mg/dl) of HDL in your blood has three times the impact of 1 mg/dl of total cholesterol, says Dr. Wilson. "If I had to choose, I'd rather my HDL went up 5 mg/dl than my total cholesterol went down 5."

There's some controversy about the level of exercise intensity you should aim for. The best data come from runners, our experts say. One study from Georgetown University (Washington, DC) of 2,906 men found that the men who jogged between 11 and 14 miles a week had levels of HDL 11% higher than those who didn't exercise (Archives of Internal Medicine, February 27, 1995). If jogging's not for you, follow Dr. Castelli's prescription--a 2-mile (or more) walk every day. "Distance counts," he says.

If diet and exercise aren't enough to score a ratio below 4 after four months, you may need cholesterol-lowering medications. But even if you do, you probably won't need to take quite as much.

That's the drill. We know it's tempting to wrap the myth around your body like a blanket and sleep on it. But if you're living on the borderline-- or over it, in enemy territory-- fat bandits may be gathering to take potshots at you. So, up and at `em! Hey, I wish I were going to Paris for this anniversary. But even more, I want my honey to go with me next time around. l

ILLUSTRATION

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By Peggy Morgan

AMERICA NEEDS CHOLESTEROL LESSONS
We hear about cholesterol all the time. We know it gunks up our bloodstreams. We know it gives heart attacks carte blanche. But do we know enough to put a dent in the year's 2 million heart attacks? Not according to an original, national survey of the nation's adults conducted by Prevention and NBC Today-Weekend Edition.*

Cholesterol exam results
Passing grades:
One thing the nation does know:
81% of us know high cholesterol increases our risk for
heart attack

One thing some of us did:
66% got our cholesterol checked in the past five years
Failing grades:
What we don't know that can hurt us:
Only 19% know what the correct safe level of cholesterol is
68% don't know their "good" cholesterol from their bad
71% don't know what their total cholesterol is
89% don't know their most important cholesterol number of all:
the ratio of total cholesterol to good cholesterol
* Results are based on telephone interviews with a nationally representative sample of 1,000 adults age 18 or older, conducted from June 6 to June 10, 1997. Margin of error: 3.3 percentage points.

THE SECRET LIFE OF CHOLESTEROL
Cholesterol is everybody's least-favorite fatty substance. Of course, our bodies need some to make new cells and hormones. But most Americans have too much, and that's what causes the trouble. Extra cholesterol tends to form big blocks of plaque, which can strangle an artery, cause pain, and kill heart muscle. "But these large, separate nubbins of blockage are only part of the problem," says Tulane medical school chancellor John LaRosa, MD. "It's really the little lakes of fat between the big blockages that are the most active and cause the most trouble. The disease exists throughout the blood vessels. Bypass surgery is just spot repair."

Think of it this way: Large areas of plaque in blood vessels are like old, dried wads of gum--thick and stable. But the vessels usually contain floppy, fatty, active lakes (more like freshly chewed gum), as well. A large, old gum-wad of plaque, even if it blocks 80% of an artery, is quite stable and unmoving. But the softer, volatile fat between the hard stuff is more likely to rupture and lead to clots. And even smaller trickles of free-floating cholesterol affect the lining of the blood vessels, causing them to tighten up when they should relax.

But--hooray!--those loose cannons of newer plaque respond to diet, exercise, and, if necessary, drugs much faster than the more fully formed gunk. So get a jump on plaque. Start eating right and exercising now!

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