Have you heard? A huge shift has occurred in medicine. For years, High-Density Lipoprotein (HDL—the ‘good’ cholesterol) and Low-Density Lipoprotein (LDL—the ‘bad’ cholesterol) were used to define our chance of having a heart attack or stroke. Doctors would treat us with statins and other medicines based on those numbers. Over the years, many people have disagreed with that approach, including me. Studies have found that other factors, such as inflammation and blood-sugar levels, are just as important if not more so. In addition, I always have advocated a multifaceted approach which encompasses diet, lifestyle, genetics, and living environment.
In November 2013, new treatment guidelines for cholesterol-lowering drugs (statins) were released. Now, when you go to your doctor, your risk for a heart attack or stroke will be assigned a number, based on a number of factors including age, sex, race (white or African American only—there’s not enough data on other nationalities yet), blood pressure, current treatment for blood pressure, total cholesterol, HDL, diagnosis of diabetes, and whether or not you’ve ever smoked. You will receive a prescription for statins if your risk of having a heart attack in the next 10 years is determined to be 7.5% or above.
Twice as Many Statin Prescriptions?
The new treatment guidelines discard the specific numerical targets that have been used to monitor treatment in the past; a strategy never proven to prevent heart attack or stroke. The problem is that many claim that the new risk-calculator grossly over estimates a person’s risk—so much so that it is estimated that twice as many prescriptions for statins will be given, and people will be advised to stay on them for far too long.
Despite the significant amount of evidence that statins have dangerous side effects and don’t reduce the risk of death for most people, and that lowering cholesterol will only slightly decrease a person’s risk of stroke and heart attack, this is where we have gotten. So where do we go from here?
What’s Missing from the New Guidelines?
Missing from the new guidelines are target parameters for treatment, and more predictive parameters of our risk. Here are a few ideas:
LDL: the Bad Cholesterol.
Cholesterol is transported throughout the body by lipoproteins, which are special protein particles in the blood. These lipoproteins are classified according to their density; two of the most important in cardiovascular disease are LDL and HDL.
Imagine your bloodstream is like a highway. The lipoproteins are like cars that carry the cholesterol and fats around your body, and the cholesterol and fats are like passengers in the cars. Scientists used to believe that the number of passengers in the car (i.e. the concentration of cholesterol in the LDL particle) was the driving factor in the development of heart disease, More recent studies, however, suggest that it’s the number of cars on the road (i.e. LDL particles) that matters most. LDL exists either as large, buoyant particles or as smaller, dense particles (sdLDL). The latter is more easily oxidized (attacked by unstable particles that cause damage, like rust on metal), has a higher affinity for vessel walls, and remains in circulation longer because it is less likely to be cleared by the liver, so it hardens the arteries more than the larger more buoyant particles. Blood-sugar issues or insulin resistance, poor thyroid function, leaky gut, infections, and genetics all may cause elevated particle number, but there is still much that needs to be learned.
What You Can Do
Because the new guidelines rightly discarded the use of LDL cholesterol in monitoring statin treatment, you may ask your doctor to instead check for LDL particle size, particle number, and oxidized LDL, which are all more closely related to stroke and heart attack risk.
Treating the cause, taking antioxidants like alpha lipoic acid and vitamin C to slow down the damaging oxidizing process, exercising, making dietary changes (like eating more fruit and leafy-green vegetables), eliminating wheat, and reducing sugar and simple refined carbohydrates, can correct these values.
HDL: the Good Cholesterol
HDL particles pick up cholesterol from many cells in the body and blood vessel walls, thereby inhibiting plaque formation and vessel narrowing. The particles then deliver the cholesterol to the liver and in turn to the small intestine for excretion. The amount of cholesterol on the particle is measured by most doctors and is considered good when high. Increasing HDL cholesterol has been a target therapy for many years. However, recent studies have proven that extremely low HDL cholesterol is not consistently correlated with early coronary heart disease and extremely high levels are not consistently protective against coronary heart disease.
More importantly, interventional trials repeatedly fail to show a protective benefit from raising HDL cholesterol levels in humans. The National Lipid Association released a statement in May 2013 that states the following:
1) Increasing HDL cholesterol can no longer be a target of therapy;
2) HDL cholesterol and particle are different;
3) Efforts to better understand HDL particle must be redoubled.
What this means to you is that your standard HDL cholesterol lab value may not mean much. Although there is a lot that remains to be learned about HDL particles, testing for HDL particle size and number instead of just HDL cholesterol can give us valuable information about your risk.
Inflammation is a Better Risk Indicator
Inflammation is the body’s response to noxious substances. In the case of heart disease, when the lining of the artery is damaged by oxidized cholesterol, cigarette smoke, and hypertension, white blood cells flock to the site, resulting in inflammation. Inflammation damages the artery walls, leaving them stiffer and more prone to plaque buildup, and makes any plaque that’s already there more fragile and more likely to burst. It is the primary cause of heart attack and stroke and is a better risk indicator than cholesterol. Tests for high-sensitivity C-reactive protein, lipoprotein-associated phospholipase a2, and myeloperoxidase can determine your levels of inflammation. Dietary changes, weight loss, exercise, and increased consumption of fish oils can slow inflammation.
Statins
Cholesterol is produced in the body and is also absorbed through our intestines. Some people have elevated cholesterol due to overproduction of it in the body; these people will benefit more from statin treatment. Other people absorb too much cholesterol in their intestines. They may benefit more from diet changes. In the event that you do start on statin therapy, you can ask your doctor to test your producer or absorber status. You can even request genetic testing to determine your risk of suffering from negative side effects from the statins.
Other strategies are available to asses and decrease your risk of heart disease. Contact your doctor to discuss all of the options available.
ProNatural Physicians Group, LLC is a network of naturopathic doctors that serve patients throughout Connecticut. The member-based organization provides administrative support such as insurance coding for service reimbursement and insurance credentialing. Interested NDs may contact Dr. Ann Aresco for membership information.
Based in Norwalk, Dr. Christopher Saltpaw is a naturopathic doctor and member of ProNatural Physicians Group. Dr. Saltpaw specializes in cardiology, blood sugar issues, men’s health and gastroenterology. He can be reached at (203) 278-2115 and www.DrSaltpaw.com. To learn more about naturopathic medicine, or to find a licensed naturopathic doctor near you, visit ProNaturalPhysicians.com. Most ProNatural Physicians Group NDs are providers for major insurance carriers. ProNatural Physicians Group, 355 New Britain Road, Kensington, CT, 06037. 860-505-0702. www.ProNaturalPhysicians.com. ProNaturalPhysicians