First Steps in Treatment

Now that you know your risk category and have looked up your treatment in the chart (see Table 4), you can begin your cholesterol-lowering program. NCEP recommends two strategies: first, therapeutic lifestyle changes, which consist of dietary changes, exercise, and weight control; and second, cholesterol-lowering medications. But there are a few steps to take before you begin your program.

Finding the Cause

First, work with your clinician to sort out any factors that might influence your cholesterol level. Several medical conditions can raise cholesterol levels. These include hypothyroidism (an illness caused by an underactive thyroid gland), diabetes, some liver diseases, Cushing's syndrome (a disorder caused by an excess of steroid hormones), alcohol abuse, and kidney trouble. Treating these conditions can improve a cholesterol profile and may eliminate the need for lipid-lowering drugs.

Some medications elevate blood lipids. Common offenders include thiazide diuretics, beta blockers, steroids (anabolic steroids and glucocorticoids, such as prednisone), progestins, amiodarone (an anti-arrhythmic drug), and retinoids and other vitamin A derivatives. Your physician may recommend changing a drug or adjusting the dose to reduce the cholesterol problem; if maintaining the drug and dosage is essential, it is usually possible to treat the cholesterol problem separately with medication.

In some people, high cholesterol reflects a genetic abnormality. For instance, an inherited disorder called familial combined hyperlipidemia affects about 1 in every 50 people, typically touching several people in the same family; it raises levels of cholesterol or triglycerides, or both. Individuals with this genetic disorder have a high risk for heart disease. A different genetic problem, called familial hypercholesterolemia, affects about 1 in every 500 people. In people with this condition, an abnormal lipoprotein receptor actually prevents liver cells from finding and removing LDL particles from the blood, leading to total cholesterol levels as high as 350–500 mg/dL. About one person in a million has a double dose of the defective gene, which can lead to levels as high as 700–1,200 mg/dL. Sometimes physical changes provide evidence that this problem exists, such as fatlike deposits around the eye or thickening of the tendons. Another tip-off is a family history of heart disease before age 55 for male relatives or age 65 for female relatives. People with this disorder generally need lifelong lipid-lowering drug treatment.

Starting the Program

If these causes of high cholesterol have been ruled out or addressed, your treatment will begin with either lifestyle changes, cholesterol-lowering medication, or both. People who have heart disease, diabetes, or kidney disease or who are at high risk for heart disease will be advised to take cholesterol-lowering medication, as will those who have high LDL levels.

According to the NCEP guidelines, people at very high risk (category 1) may want to consider striving for an LDL level below 70 mg/dL to lower risk of heart disease even more. For people at high risk (category 2), the goal is an LDL level below 100. For people at moderately high risk (category 3), the goal is less than 130 mg/dL, although the NCEP gives you and your doctor the option of aiming for less than 100 mg/dL if your risk profile calls for it.

People at moderate risk (category 4) should aim for an LDL of less than 130 mg/dL, and for those in the lowest risk group (category 5), an LDL of up to 160 is acceptable. Note that updated NCEP guidelines state that these numbers aren't absolute cutoffs. So if your doctor recommends medication even though you are close to your LDL target, it makes sense to try to lower your LDL by 30% or 40%.

Your Cholesterol-Lowering Diet

One of the safest and cheapest ways to treat high cholesterol is to change your eating habits. In a nutshell: Eat less saturated and trans fats. An overweight person who has been subsisting on cheeseburgers and fries can lower total cholesterol levels by 25% or more by switching to lean meats, vegetables, fruits, and whole grains. Careful dietary choices by a highly motivated person (with close medical supervision) can even reverse coronary artery plaques that are already established. That said, even on a moderately low-fat diet, the average person will see a drop of 5%–10%. A 15% decrease can result from a more severely restricted diet. Even these smaller changes are important to your health.

Eating the right fats

In the average American's diet, about 35% of calories come from fat. Your goal should be to get no more than 25%–35% of your total daily calories from fat, including less than 7% from saturated fat. The NCEP guidelines also recommend consuming less than 200 mg of dietary cholesterol (about the amount in one large egg yolk) per day.

Keep track of what you eat in a typical day. The labels on packaged foods and a calorie counter that includes fat grams can help you determine what percentage of the calories you eat comes from fat. A growing body of research indicates that the types of fat you eat are at least as important as the amount you eat. Practically speaking, bad fats include saturated fats and trans fats, while good fats are primarily the monounsaturated fats and polyunsaturated fats, although the latter have lost some of their luster since being shown to lower HDL a bit.

Saturated fats are solid to semi-solid at room temperature and include the fats in meat, dairy products, and eggs, as well as some vegetable oils, particularly the tropical oils (palm, palm kernel, coconut, and cocoa butter). Most saturated fats stimulate LDL production in the body. Reducing the amount of saturated fat in your diet can lower your LDL.

Unsaturated fats, which tend to be liquid at room temperature, include both monounsaturated and polyunsaturated fats. Olive, peanut, sesame, and canola oils are rich in monounsaturated fats, while soybean, corn, cottonseed, safflower, sunflower, and fish oils are high in polyunsaturated fats. In contrast to LDL-raising saturated fats, both monounsaturated fats and polyunsaturated fats have some ability to lower LDL.

Trans fats are created when food manufacturers solidify unsaturated liquid oils to create firmer margarines and shortenings. They use a process called hydrogenation that essentially saturates the oils with hydrogen atoms. The resulting compounds — trans fats — have been shown to raise LDL and lower HDL levels in the blood and to contribute more to developing heart disease than even saturated fats do. An expert panel from the Institute of Medicine concluded that trans fats have no known health benefit and that there is no safe level of consumption. Growing data on the hazards of trans fats prompted the FDA to pass a regulation that now requires food manufacturers to list the trans fat content of their products.

Eating large amounts of good fats was once touted as a way to protect against heart disease, but this megafat therapy has fallen out of favor because polyunsaturated fats, once in the body, can undergo a step called modification, which may be the earliest trigger of plaque formation. Monounsaturated fats do not undergo modification, and they lead to lower LDL cholesterol levels when substituted for saturated fats in the diet. Replacing saturated fats with monounsaturated fats — for example, using olive oil instead of butter at the table — is one way to improve a wayward lipid profile, as long as you aren't just adding monounsaturated fats and forgetting to cut back on the saturated fats.

For those who do not respond to dietary changes in fat and cholesterol intake, the guidelines recommend two additional steps. First, try increasing your intake of soluble dietary fiber, such as that found in oat bran (see "Fiber"); second, increase your consumption of plant stanols and sterols, which are found in an increasing number of food products (see "Plant sterols and stanols").

Everyone is different

There is a wide variation in how people's cholesterol levels respond to dietary cholesterol and to heart-healthy diets in general. For some people — call them responders — cholesterol levels are a direct reflection of the amount of fat in their diet, and so diet may make a difference. For others — the nonresponders — cholesterol levels are not closely linked to dietary intake of fats, but rather are a direct reflection of how much cholesterol the liver makes. A study done in 1997 at the Human Nutrition Research Center on Aging at Tufts University looked at how 120 men and women responded to a low-fat, low-cholesterol diet recommended by the NCEP, called the NCEP Step Two diet. On average, LDL levels dropped. Yet even though everyone ate the same thing — the researchers provided the volunteers with all their food and drink — the average result masked a wide range of LDL responses, ranging from a 55% decrease to a 3% increase among men, and a 39% decrease to a 13% increase among women.

Such variability is even more pronounced for dietary cholesterol. In some people, the amount of cholesterol in the diet has a strong influence on the amount of cholesterol in the bloodstream; in others, there's little connection. Because there isn't any simple way to test whether you are a responder or a nonresponder to dietary fat or cholesterol, the safest approach is to limit them both.

There are two important messages from the research on responses to dietary fat and cholesterol:

1. Determine whether diet changes work for you. Say your cholesterol is creeping up into the high range, and your physician suggests that you try a lower-fat, lower-cholesterol diet for three to six months. You make an effort to do so. But at the end of the trial period, a blood test shows that your cholesterol levels haven't budged. Your physician might misinterpret the lack of change and chide you for not sticking with the new diet. But if you have followed the diet carefully, make sure the doctor knows it. You may belong to the nonresponder group and need a different kind of diet, or medication, to control your cholesterol.

2. One size doesn't fit all. When a friend or relative tells you how much his or her cholesterol level dropped after trying a particular diet, you may be tempted to try the same diet. But if after a few months you discover that the diet has no effect, chalk it up to genetic and physiological differences. There just isn't a one-size-fits-all recommendation for diet or cholesterol consumption, which means you may have to try several different diet and exercise approaches to find one that works for you.

Your Exercise Program

Along with diet, regular exercise is an essential ingredient in any recipe for improving an unhealthy lipid profile. Exercise can lower LDL and triglycerides and raise HDL Plus, exercise is a crucial element in any weight-control program, and the NCEP's guidelines for therapeutic lifestyle changes emphasize weight control as an important component of treatment.

Almost as important, exercise can overcome the unfortunate tendency of a low-fat, lower-calorie diet to reduce levels of HDL, particularly in women. In one classic study, called the Stanford Weight Control Project, women on a low-fat diet saw their HDL levels drop 7% during a year of dieting. But women who combined diet and exercise — about eight miles of brisk walking or jogging a week — increased their HDL levels in addition to losing weight and lowering their levels of total and LDL cholesterol. For men, a low-fat diet alone didn't change HDL levels, but diet plus exercise substantially increased them.

Regular physical activity has plenty of other heart-healthy benefits. It trains your heart and lungs to deliver blood and oxygen to your tissues more efficiently and with less stress and strain. It lowers blood pressure. It protects against the development of type 2 diabetes by helping muscle cells become more sensitive to insulin. For people who already have diabetes, exercise can reduce the amount of medication needed to control blood sugar and, in some cases, eliminates the need for drugs altogether. Exercise can also strengthen muscles and bones — warding off potentially disabling falls and osteoporosis, the gradual loss of bone that is the primary cause of hip, wrist, and spine fractures among older people.

If you have heart problems, talk to your doctor before you start an exercise routine, or if you experience chest pain during a workout. You can minimize the hazards of physical activity by starting an exercise regimen gradually, avoiding overexertion, and seeking medical attention promptly if you have chest pains, leg cramps, undue shortness of breath, palpitations, or lightheadedness. Because such symptoms may suggest heart, lung, nervous system, or blood vessel disorders, a doctor's evaluation is important.

For heart health, exercise should be slow, steady, and frequent. Health experts from the U.S. Surgeon General to the American Heart Association and the American College of Sports Medicine recommend exercising for at least 30 minutes on most, if not all, days of the week. That 30 minutes can be divided into two or three segments, if needed. In other words, one or two brisk walks a day are more valuable than a heavy weekend workout that leaves you sore and unmotivated for several days. The Institute of Medicine upped the ante: It recommended that people get one hour of exercise on most days. While the report pointed out that one hour of exercise is better than 30 minutes, the fact is that if you're inactive, any amount of exercise is better than none.

If you're already somewhat active, however, the more exercise you get, the better. A landmark study of 17,000 Harvard alumni suggests that men who burn an extra 700 or so calories a week by walking, playing sports, or doing some other form of exercise (see Table 6 for some examples) live longer than those who aren't active. The health benefits continue to increase up to about 2,000 calories a week, then seem to level off from there. Information from a long-term study of female nurses shows similar trends for women.

Getting started with exercise

It's best to check in with your doctor before starting an exercise program. But if you can answer "no" to all of the following questions, it's probably safe for you to start exercising.

• Has your doctor ever suggested that you have heart trouble?

• Do you frequently have pain in your heart and chest?

• Do you often feel faint or have spells of severe dizziness?

• Has your doctor ever said your blood pressure was too high?

• Has your doctor ever told you that you have a bone or joint problem, such as arthritis, that has been aggravated by exercise, or might be made worse by it?

• Are you over 65 and not accustomed to vigorous exercise?

• Is there a good reason not mentioned here why you should not exercise?

If you answered "yes" to any of these questions, see your physician before exercising. He or she will take a medical history, conduct a physical examination, and — if you are over age 35 and sedentary — may suggest a test called an electrocardiogram to look for signs of subtle coronary artery disease, abnormal heart size, or abnormal heart rhythms.

If the physical exam or electrocardiogram raises any suspicion of a cardiac problem, your physician will probably recommend an exercise stress test. But keep in mind that stress tests are more useful for uncovering exercise-induced heart-rhythm disturbances, evaluating exercise capacity, and establishing maximum and target heart rates for an exercise program than for ruling out coronary artery disease. Stress tests rarely spot heart problems in people who don't have any symptoms.

Next, you can determine your maximum and target heart rates so that you can exercise at a level that improves your cardiovascular fitness. To calculate your maximum heart rate, subtract your age from 220. For a 50-year-old, that would be 220 minus 50, or 170 beats per minute. Now you can determine your target heart rate. To do this, you'll need to take your pulse during exercise. Some exercise machines will do this for you, but it's best to simply stop during exercise and immediately take your pulse.

People who are sedentary can benefit from exercising at 60% of their maximum heart rate. For a 50-year-old, this would be 170 times 0.6, or 102 beats per minute; for a 65-year-old, it would be 220 minus 65 times 0.6, or 93 beats per minute. The goal of your program should be to exercise with enough oomph to maintain your target heart rate for about 20 minutes. As you become more fit, you can push the target heart rate to 75%.

You don't need to buy a heart monitor to take your pulse. You can check your heartbeat by finding the pulse point on the side of your neck or on your wrist; count the number of beats as your watch ticks off 6 seconds, and multiply that number by 10. Even this isn't absolutely necessary — walking, biking, or running to the point at which you are just able to say four or five words between breaths correlates well with the aerobic benefit of heart rates in the 110–130 range. In short, exercise shouldn't seem like punishment, but it should feel like exertion.

Some people, including those with congestive heart failure, serious arrhythmias, unstable angina, uncontrolled high blood pressure, significant aortic valve disease, aortic aneurysm, or uncontrolled epilepsy or diabetes, shouldn't exercise or should exercise only under closely monitored or supervised conditions. People with ischemic heart disease or other significant cardiovascular problems should consult their physicians for an appropriate exercise program.

Monitoring Your Progress

Starting a program of dietary change and exercise is a great first step for anyone with high cholesterol. To make sure your program is working, have your cholesterol levels measured after two or three months and again at six months. It may take that long before the full effect of your lifestyle changes becomes evident, both because it takes time for people to make a real change in their habits and because the body's actual response can be gradual. If the follow-up measurements show that you have reached desirable levels of LDL, HDL, and triglycerides, continue to have follow-ups every six months. Note, though, that some insurance companies don't cover multiple blood tests.

If your blood cholesterol level does not respond to three months of diet and exercise, the NCEP recommends that you visit a dietitian for a more thorough review of food choices and tips on more and better ways to cut back on fat intake. If your cholesterol levels still don't improve, drug therapy might be in order.