Cholesterol: The Lowdown on the Highs and Lows

When it comes to cholesterol numbers, we hear the medical professionals’ — and the pharmaceutical companies’ — constant calls to get our cholesterol lower, lower, lower. So it may surprise you to know that, despite its thoroughly negative reputation, we don’t truly want to be rid of our cholesterol completely.

“There’s a purpose for it; there’s a reason why we have it,” Dr. Tatjana Sljapic, electrophysiologist with WellSpan Cardiology in Lancaster, said. “[Cholesterol] isn’t all bad. Your body actually needs it to produce vitamin D. It builds cell walls and helps us digest fats. Some cholesterol you need — it’s just the high levels that are detrimental.”

And the guidelines for those high levels, established by the National Cholesterol Education Program through the National Institutes of Health, change all the time, Sljapic said.

“The majority of physicians, like me, have a rule that everybody’s LDL cholesterol should be 130 (or lower),” she said. “If somebody had a previous heart attack; if they have diabetes, which is an aggressive disease; or if they had a stroke, open heart surgery, or a stent, the majority of physicians in cardiology would keep it below 70.”

Those with two or more risk factors — hereditary predisposition, obesity, smoking, etc. — should shoot for a cholesterol number below 100.

Produced by the liver, cholesterol is a fatty, waxy substance that, in excess, builds up in the arteries and hardens into plaque (atherosclerosis). This buildup is what narrows and eventually blocks the flow of blood through the artery, which results in rupture or heart attack.

So while some cholesterol is produced internally, the rest of it enters our bodies through our mouths. In a country with an established obesity epidemic and where, according to the Centers for Disease Control and Prevention, 1 in 6 adults has high cholesterol, Americans are being urged left and right to take a hard look at our diets and make changes for the better.

Those with diets high in saturated fats and trans fats put themselves at huge risk for developing high cholesterol, which, in turn, spikes their risk for heart disease, the leading cause of death for both men and women in the United States.

Also on cardiologists’ radar are triglycerides, another type of fat now measured alongside cholesterol levels.

“Up until a few years ago, we did not quite understand it in terms of cardiovascular risk,” Sljapic said. “The targets now for triglycerides are below 150 for cardiovascular protection. In the past, we’d have patients at 300; we never thought that was important, but the data has shown otherwise.”

Although some triglycerides are necessary for health and energy, excessive amounts contribute to coronary artery disease. These fats are often found in simple carbohydrates, starchy foods, alcohol, chocolate, butter, and high-fat meats.

“In men, it’s beer. In women, it’s ice cream,” Sljapic chuckled.

It’s important to note that not all cholesterol is created equal. LDL cholesterol, nicknamed the “bad” cholesterol, increases inflammation and contributes to plaque formation in the arteries. This is the number we strive to keep low.

HDL, or “good” cholesterol, is a number we strive to keep on the higher side, with 70 being the target. Sljapic said below 40 for men and below 50 for women is considered too low. HDL above 75 has been shown to prolong life, known as longevity syndrome — possibly one of the only syndromes you genuinely want.

“[HDL] removes the excess cholesterol from the blood,” Sljapic explained. “It’s protective. I’ve never seen a patient with a heart attack who had an HDL of 80 in my life.

“The interesting thing is that low HDL will actually increase your cardiovascular risk,” she continued. “But the problem is there’s really not enough science to support elevating it [via medications or supplements]. None of these measures has really led consistently to better outcomes.”

Until menopausal age, women’s cholesterol levels tend to be a bit lower than men’s.

“Men do not have the benefit of the protective effect of estrogen that women of childbearing age have,” Sljapic said. “And then at menopause, we kind of equalize. The estrogen is not there to protect you anymore.”

But beginning hormonal replacement therapy solely to replace estrogen and its cardiovascular protective effects, Sljapic warned, is not recommended and has not been proven beneficial. Instead, a cholesterol-lowering statin drug, such as Crestor, Lipitor, or Zocor, should be prescribed.

Patients with elevated LDL cholesterol are usually encouraged to take part in a Therapeutic Lifestyle Changes (TLC) program, which focuses on dietary adjustments (specifically the reduction of saturated fats), physical activity, weight management, and smoking cessation. This lifestyle program works in conjunction with prescribed medications.

“I’m a big believer in statin therapy. They’ve been tried and tested for the past 35 years,” Sljapic said. “If people took statins, coronary disease would not be extinct but it would be tremendously less of a burden.”

Statins reduce the LDL cholesterol produced by the liver; some — but not all — have been shown to elevate HDL and reduce triglycerides, too.

So why are so many patients disinclined to try or stick with statin drugs? Sljapic said some people simply don’t like taking medications. Some would prefer to focus exclusively on lifestyle modifications. Some are put off by the occasional side effects, such as myositis (muscular aches and pains).

Sljapic theorizes that many patients are started on statins at too high a dose; then, when they cannot tolerate the side effects, they are reluctant to give the medications another try. She encourages patients to try a different statin and start at the lowest possible dose and then go higher if necessary.

The inescapable reality, though, is that a healthy lifestyle — “move more, eat less,” as Sljapic puts it — is essential to maintaining appropriate cholesterol levels, avoiding heart disease, and achieving longevity.

“There are areas in the world where people, for whatever reason, have a high percentage of living to be 100. And it’s not only that they live to be 100, but they’re actually very healthy,” Sljapic said. “They don’t have heart disease, they don’t have atrial fibrillation, they do not have dementia. The common thread … is that these people move.” BW