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A Complicated Puzzle
According to National Cholesterol Education Program (NCEP) guidelines issued by the federal government and supported by leading researchers and the American Heart Association (AHA), desirable total cholesterol results should be lower than 200 mg/dL. Levels from 200 to 239 mg/dL are considered borderline high. Total cholesterol levels of 240 mg/dL and above are considered high.
Your total cholesterol levels, however, do not paint a complete picture of the health of your arteries. Because not all cholesterol is bad, you need to find out what type of cholesterol you have. Remember that cholesterol is essential to the health of every cell in your body and to the production of your sex hormones. Good cholesterol, or HDL, actually helps to maintain healthy cholesterol levels. To fully understand the health of your arteries and what is flowing in your bloodstream, you also need to find out about the levels of other blood fats, known as triglycerides.
Half the people whose total cholesterol levels come within the “desirable” levels have heart disease, so simply achieving this target does not guarantee that you are not at risk of heart disease. To truly evaluate your risk, you need to take into account all of the risk factors that apply to you and pay particular attention if you have a family history of heart disease. Regardless of cholesterol levels, it is a good idea for everyone to observe healthy lifestyle habits, not only to lengthen your life but to increase the quality of those additional years.
The Body’s Production and Transfer System
The major players in the cholesterol picture are the liver and the blood fats. To support bodily functions, the liver synthesizes cholesterol, lipoproteins, triglycerides, and phospholipids. The liver manufactures both LDL and HDL cholesterol, manages their release into the bloodstream, and collects them back from the bloodstream. Blood fats are the building blocks the liver uses to produce cholesterol.
The body uses LDL cholesterol to build cell membranes, create essential hormones, and to form digestive enzymes. This LDL cholesterol needs to be transported throughout the body. However, cholesterol is fatty and blood is watery; oil and water do not mix. This dilemma is resolved in the liver, where cholesterol is combined and coated with proteins to create lipoproteins. The protein coating enables fat to travel in the bloodstream. The various types of lipoproteins are outlined in the following chart.
The Liver: Cholesterol Manufacturing Plant
To simplify how this cholesterol transportation process works in your body, imagine a pickup and delivery service to and from the liver, which is the cholesterol manufacturing plant. Imagine that the lipoproteins are like delivery trucks that carry packages of cholesterol in the bloodstream. The function of the HDL “delivery trucks” is to pick up excess LDL cholesterol “packages” from the bloodstream and return them to the liver for repackaging as needed.
Another type of lipoprotein, VLDL, or very low-density lipoprotein, acts as the delivery truck that transports the LDL cholesterol throughout the body and delivers it to all the cells. The cell receptors are the drop-off stops where the LDL deliveries are made. The VLDL delivery truck also carries blood fats called triglycerides. These fats are available for immediate use by the body as energy, or for storage in fat cells for later use.
In a healthy body, this efficient manufacturing, pickup, and delivery system maintains perfect balance. Cells pick up the LDLs that they need to perform their functions at the receptor stops. HDLs pick up excess LDLs that the cells don’t need and deliver them back to the liver for repackaging. Trucks circulate constantly, at all hours of the day and night, providing energy for quick fuel and for minimal storage reserves. The liver manufacturing plant naturally manages the entire process.
Fact: The primary functions of the liver include metabolizing carbohydrates, proteins, and fats; storing and activating vitamins and minerals; forming and excreting bile to digest fats; converting ammonia to urea for elimination; metabolizing steroids; and acting as a filter by removing bacteria from blood. The liver also detoxifies substances such as drugs and alcohol.
Breakdown of the System
Modern living conditions, however, overload and strain the system. By eating too much and moving too little, people make it all too easy for this delicately balanced delivery, pickup, and storage system to break down. The efficiency begins to fail when more LDL packages are transported in the bloodstream than are needed by the body’s tissues. This excess LDL cholesterol continues to circulate in the bloodstream, increasing fat levels in the bloodstream and contributing to congestion on the “roadways.”
If this excess LDL occurs at the same time that too few HDL trucks are available to collect and deliver it back to the liver for recycling, then the LDL cholesterol starts to collect like piles of litter on the arterial walls in places where it finds areas of inflammation. Certain packages of this arterial litter become oxidized, and they begin the process that leads to the clogging up of the “roadways” or arteries. Over time, this collection of debris on the arterial walls leads to a complete blockage, which then prevents blood flow that delivers essential oxygen for survival to the body’s tissues. The body’s tissues begin to die. If this happens in the muscle tissues of the heart, the result is a heart attack that can lead to death.
The leading causes of the system breakdown are the following:
Scientists worldwide continue to conduct research so they can thoroughly understand the roles of the different types of lipoproteins and blood fats in the mechanisms behind heart disease. Evidence from research suggests that there are seven LDL subtypes and five HDL sub-types. Some of these subtypes are more harmful and others are more beneficial to health. For LDL cholesterol, particle size plays a significant role in the risk picture. People with higher numbers of the small dense LDL particles, rather than the large fluffy LDL particles, have a significantly higher risk of heart attack.
What Is Plaque?
Plaque is composed of oxidized LDLs and calcium in the bloodstream, as well as other cellular debris, or “litter,” that gets caught in the fatty (“lipid”) deposits. As the deposit grows larger, it hardens due to the increase in the amount of calcium. Plaque is living and growing. It has an outer layer of scar tissue that covers the calcium and fats, as well as the white blood cells that responded to the damaged arterial wall within.
Eventually the buildup of plaque can decrease or block blood flow to the heart or to the brain, starving these organs of essential oxygen and causing chest pains, a heart attack, or a stroke. This plaque buildup is known as atherosclerosis and is one of the most common types of heart disease. Plaque can begin to accumulate in childhood and develops so slowly in our bodies that its presence often grows without any signs to make us aware of it.
The Endothelial Lining
The endothelium, or endothelial lining, is the tissue that lines the inside of our blood vessels, through which our nutrients travel in the bloodstream. Evidence from research studies tells us that when this inner lining of the vessel walls becomes inflamed, cells stick to it and begin the formation of plaque. Scientists have been conducting research on how to maintain the health of the endothelial lining to prevent the initial formation of plaque.
Fact: Heart diseases are the number-one killer of women in America. Heart diseases kill more than half a million women each year-approximately one death per minute. The American Heart Association reports that heart diseases claim more women’s lives than the next seven causes of death combined.
High-density lipoprotein (HDL) cholesterol, or the pickup truck fleet, is known as the “good” cholesterol. When you understand how the liver’s manufacturing and transport system works, it’s easy to see why the HDLs are considered good-because HDLs help clear the excess LDL cholesterol from your arteries. For a healthy heart and circulatory system, your HDL cholesterol levels should be higher than 40 mg/dL. The higher the level of your HDLs, the better it is for your health. People who have low levels of HDL cholesterol are at higher risk for heart disease.
According to the NCEP guidelines, an HDL level of 60 mg/dL is considered a negative risk factor. A negative risk factor is like a bonus point that can negate or counteract another risk factor (such as having excess weight) when you are calculating your total risk score. Since knowing the amount of your HDL cholesterol is an important aspect of assessing your overall risk of heart disease, it’s a good idea to have your HDL cholesterol levels measured when you have your total cholesterol checked.
Low-density lipoprotein (LDL) cholesterol is known as the “bad” cholesterol; however, LDL cholesterol is bad for your body only if you have too much in your bloodstream or you have too much of the particularly harmful type. LDL cholesterol is an essential building block for cell membranes and the substance from which hormones, including cortisol and testosterone, are manufactured. The amount of LDL cholesterol that exceeds what your body needs, however, flows through your bloodstream and increases the likelihood of the formation of plaque that can block blood flow.
Fact: The cost of cardiovascular disease and stroke in the United States in 2003 was estimated at $351.8 billion, including $209.3 billion indirect costs and $142.5 billion in indirect costs, according to the Centers for Disease Control.
NCEP guidelines recommend that near-optimal levels for LDL are under 130 mg/dL. If you are at risk for heart disease due to other risk factors, then the recommended level for LDLs is under 100 mg/dL. If you are at “very high” risk, the guidelines recommend aggressively lowering LDL to less than 70 mg/dL.
A healthy total cholesterol level includes different forms of cholesterol: LDL, the bad cholesterol that builds up in our arteries, and HDL, the good cholesterol that collects bad cholesterol from the blood vessels. If you have a lower level of cholesterol, you reduce the likelihood that you will have heart disease. If your total cholesterol level is very high (above 240), you need to talk to your health-care provider about how to lower it. If your cholesterol levels are only slightly elevated, you can take many steps on your own as outlined in this book to lower it to an ideal, healthy level.
The Ratio of Total Cholesterol to HDL Levels
One method to predict your risk of heart disease is to look at the ratio of total cholesterol to the level of HDLs or good cholesterol at the time of your test. High levels of HDL in your bloodstream are good for your health. To calculate your ratio, divide your total cholesterol number by your HDL cholesterol. For men, a ratio of 4.5 to 1 or less is desirable. For women, the desired ratio is 4.0 to 1 or less.
Keep in mind, however, that this ratio is used as a rough predictor of risk, not to determine therapy. Your health-care provider should advise treatment to improve your overall blood lipid profile based on knowledge of levels of LDL and HDL cholesterol and triglycerides. It is not enough to simply know total cholesterol and HDL levels, especially for planning treatment, as it does not provide a complete picture of the health of the circulatory system.
Triglycerides, also referred to as TRGs, are another type of fat that circulates in your bloodstream in the same way as HDL and LDL cholesterol. TRGs are composed of a sticky substance (called glycerol) and fatty acids. They can provide your body with a source of energy if needed. Triglyceride levels spike immediately after you eat and decrease slowly as the body processes nutrients from food that has been consumed. If muscles are working and active, the triglycerides can provide needed fuel. If the muscle cells do not use the circulating triglycerides to create energy, the TRGs are eventually deposited in the body’s fat stores.
Since eating affects TRG levels, you should fast for at least nine to twelve hours before you have a lipid profile test. After you undertake this nine- to twelve-hour period without eating or drinking, the levels of TRG that are circulating in your bloodstream will more accurately reflect how much of these fats are consistently present in your blood.
A desirable level of TRG is less than 150 mg/dL. People who are overweight, who drink alcohol excessively, who are diabetic, or who have other disorders are prone to have elevated triglyceride levels. Women tend to have higher triglyceride levels than men.
Evidence from research shows that the risk of heart disease increases when the triglyceride level is too high, particularly when a person simultaneously has low levels of HDL cholesterol. Triglyceride levels of 500 mg/dL or above are associated with the risk of pancreatitis, which can lead to pancreatic cancer. Treatment is indicated for triglyceride levels above 150 mg/dL.
Frequently Asked Questions
If I can’t live without cholesterol, why is high cholesterol a problem?
Too much cholesterol in the blood can lead to blockage of the arteries. Fat-like deposits may build up inside arteries that provide blood to the legs, blood to the brain, or blood to the heart.
When blood flow through a coronary artery (blood to the heart) is completely blocked, an area of the heart muscle does not receive the oxygenated blood it needs to survive. When this happens, a heart attack occurs. Plaque can also build up in the carotid arteries that supply blood to the brain. If this breaks free and a clot of it goes to the brain, it can cause a stroke. When plaque builds up in the blood vessels of the legs, it can cause leg pain, fatigue, cramping, or feelings of heaviness.
This condition is known as peripheral arterial disease. When plaque builds up in the arteries that supply blood to the male sex organs, erectile dysfunction or impotence can result.
When I test my cholesterol, what information do I need to get?
The federal government guidelines recommend that every person who is age twenty or older should have a fasting lipoprotein profile at least once every five years. This test measures total cholesterol, LDL cholesterol, HDL cholesterol, and triglycerides. All of this information is relevant to get a picture of the health of your circulatory system. For some individuals, an even more detailed breakdown of the sub-types of LDL and HDL cholesterol may be relevant.
Fact: People with very high cholesterol levels can reduce both their cholesterol and level of risk for a heart attack. According to the American Heart Association, drug therapy combined with lifestyle changes helps people with very high cholesterol reduce heart attacks by 34 percent and cardiac deaths by more than 40 percent.
What is the difference between good and bad cholesterol and triglycerides?
HDLs are known as the good type of cholesterol because their function is to gather excess LDL cholesterol in the body and return it to the liver. LDL cholesterol, although it serves a valuable purpose, is referred to as bad cholesterol because too much LDL cholesterol is harmful to the body. The reason excess LDL cholesterol is harmful is because it contributes to plaque formation on the inside of inflamed blood vessel walls.
Triglycerides are not similar to LDLs in terms of their function in the body, but they are similar in the way they cause harm to the body when present in excess. Like LDLs, triglycerides also travel through the bloodstream. Since triglycerides are a type of sticky blood fat, they also contribute to formation of plaque inside damaged blood vessel walls. Therefore, in general, most people want to increase HDL cholesterol levels and decrease LDL and triglyceride levels.
How can I increase my HDL cholesterol levels?
HDL cholesterol responds well to lifestyle changes. If you increase your physical activity each day or exercise regularly, it will stimulate the liver’s production of HDLs. Losing excess weight can also improve your HDL profile. If you smoke cigarettes, you will increase your HDL levels simply by quitting your habit. If your HDLs are less than 35 mg/dL, you may need drug therapy. Be sure to ask your health-care provider what strategies are most suitable for you.
How does being more active help to lower cholesterol?
Regular physical activity can increase your HDL cholesterol and reduce triglycerides. Since triglycerides are a blood fat, they are available to the body as a source of fuel for muscular activity. Therefore, people who are active can use up the triglycerides in their bloodstream as a source of energy.
Evidence from numerous research studies shows that moderate exercise, such as brisk walking, that adds up to a total of thirty minutes on most days of the week can improve your health. The great news is that you do not need to exercise vigorously or for hours at a time to achieve health benefits. In addition to burning up excess fats, moderate exercise also helps to reduce stress, which further enhances your well-being.
How does smoking affect cholesterol levels?
Cigarette smoke contains many toxic chemicals. These not only destroy lung tissue, they also contribute to plaque formation and adversely affect the nervous system, causing both heart rate and blood pressure to elevate. These chemicals contribute to reducing levels of good HDL cholesterol and accelerating the process of heart disease. While it is difficult to kick the smoking habit, the benefits of not smoking begin as soon as you quit.
If high cholesterol runs in my family, what, if anything, can I do to lower it?
Approximately 10 percent of American adults with high cholesterol are genetically predisposed to have this condition. If you have a family history of heart disease, it is important for you to work together with your healthcare provider to monitor your heart health with routine checkups annually. Lifestyle factors such as physical activity, proper nutrition, not smoking, and effective stress management still matter. For you, it is even more important to lead a healthful lifestyle. Even with a healthy lifestyle, your physician may still recommend drug therapy. With today’s tools and knowledge, much can be done to manage the risks that you inherited. The information in this book is a great first step toward arming yourself with the necessary knowledge to empower yourself to positively manage your own health and well-being.
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