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Copyright (c) 1991   Tribune Media Services, Inc.


Health Update

by Dr. Allan Bruckheim

Cholesterol Control:  A Lifetime Plan


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CHOLESTEROL AWARENESS IN AMERICA

     High blood cholesterol is one of the three major risk factors for heart
disease.  Cigarette smoking and high blood pressure are the other two.
Fortunately, all three risk factors can be modified--that is, you can change
them, and lower your risk of developing heart disease.
     Most Americans are acutely aware of cholesterol.  Newspapers and
magazines run frequent articles on it, best-selling books tell how to control
it, and grocery store shelves are lined with products boasting that they don't
contain it.  Cholesterol is such an important public health concern that more
than 20 health groups, including the American Heart Association and the
National Heart, Lung and Blood Institute have joined a campaign, called the
National Cholesterol Education Program, to promote lower cholesterol levels.
     Unfortunately, the more we see and hear about cholesterol, the more
complicated and confusing the message gets.  What exactly is cholesterol?  Why
is some cholesterol "good" and some "bad"?  What is the difference between
"dietary" cholesterol and "blood" cholesterol?  Does diet really affect
cholesterol levels?  Can exercise lower cholesterol levels?  Can reducing
cholesterol protect you from heart disease or premature death?
     This booklet is designed to end your confusion over cholesterol.  It
includes the latest, most reliable scientific information on this complex and
important topic.  You can do something to lower your cholesterol level--and
lower your risk for heart disease.
     Here is the information you need to begin a lifetime plan to control
cholesterol and keep your heart healthy.  The cornerstone of cholesterol
control is dietary modification.  Other measures, and sometimes
cholesterol-lowering medications, may also be appropriate.  After reviewing
your medical history and measuring the amount of cholesterol in your blood,
your physician can recommend the approach that is best for yo

WHAT IS CHOLESTEROL?

     Cholesterol is a waxy, fat-like substance that is an important part of
the normal system of blood fats found in humans and animals.  Cholesterol is
not bad by itself; in fact, it is essential to several vital body processes.
It helps produce hormones, it contributes to development of the brain, and it
aids the functioning of the nervous system.
     It is not necessary to consume cholesterol in your diet.  The liver
manufactures all that your body needs:  it also processes the additional
cholesterol that comes from the foods you eat.  Cholesterol becomes a problem
only when the body makes too much of it.  The bloodstream carries cholesterol
from the liver to other body cells.  Excess cholesterol that the cells don't
need can collect on the lining of the blood vessels.  This can cause a
condition called coronary atherosclerosis--that is, the buildup of fatty
deposits, or plaque, in the arteries.
     These fatty deposits narrow the blood vessels, making the heart work
harder to pump blood through.  Blood clots (thrombosis) can also form around
these fatty deposits.  Atherosclerosis can cut off the supply of blood
carrying oxygen and other vital nutrients to the heart and other organs.  Poor
circulation of blood to the legs can cause crampy pains that doctors call
intermittent claudication.  In an artery supplying the heart, clogging can
disrupt the normal beating of the heart and Lead to a heart attack or chest
pain (angina).  If a blood vessel nourishing the brain becomes clogged, the
decreased supply of oxygen and nutrients could lead to a stroke.

LESS CHOLESTEROL MEANS LOWER RISK

     The bad news is that the higher your total blood cholesterol level, the
greater your risk of heart disease.  The good news is that you can reduce your
risk of heart disease by lowering the amount of cholesterol in your blood.
According to the American Heart Association, for every I percent that you
lower blood cholesterol levels, you reduce your risk of heart attack by 2
percent--in other words, you are two times less likely to have a heart attack
than if your levels remained high.
     But does lowering cholesterol actually reduce the risk of death from
heart disease?  This has been an area of considerable scientific controversy.
For many years, there was no evidence that people who reduced their
cholesterol levels lived any longer than those who didn't--even though they
were less likely to have heart attacks.  Because there was no clear scientific
evidence that reducing cholesterol saved lives, some scientists and physicians
were skeptical about whether people should make drastic changes in lifestyle
and diet to control cholesterol.
     Now the evidence is in.  A 10-year scientific study of more than 800
people proved that those with normal hearts whose blood cholesterol is brought
down from abnormally high levels live longer than those whose cholesterol
levels remain high.  Furthermore, people who lowered their cholesterol levels
were less likely to need surgery to unclog blocked arteries.  Lowering
cholesterol to reduce the buildup of atherosclerotic plaque in blood vessels
also protected against heart attacks.
     The knowledge that lowering cholesterol levels can keep your heart
healthier and help you live longer should give you all the incentive you need
to watch your cholesterol levels.

BLOOD CHOLESTEROL AND LIPOPROTEINS

     The kind of cholesterol in your blood is as important as the total
amount.  The different types of cholesterol are described in terms of the way
they are transported through the bloodstream.  Cholesterol is a fat, so it
cannot mix with blood, which is water soluble.  Therefore, cholesterol is
carried through the bloodstream in protein "packets" called lipoproteins.
These are of various sizes and weights (or densities).
     The two most common kinds of cholesterol are large low-density
lipoproteins (LDL) and smaller, denser lipoproteins, called high-density
lipoproteins (HDL).  LDL and HDL account count for most of your blood
cholesterol, but there are other kinds of blood fats as well, including very
low-density lipoproteins (VLDL), intermediate-density lipoproteins (IDL), and
triglycerides.
     Normally, most of the cholesterol circulating in your bloodstream is
carried by LDL.  LDL is often called "bad" cholesterol because it promotes
heart disease.  Extra LDL cholesterol that isn't used by the body in its
normal functions tends to "stick" to the walls of the arteries.  These
deposits can develop into atherosclerosis.
     HDL cholesterol is considered "good" because it appears to carry
cholesterol back to the liver for processing or removal from the body.  HDL
may help prevent the formation of fatty plaques in the arteries, and protect
against heart disease.

'DIETARY' VS. 'BLOOD' CHOLESTEROL

     "Dietary" cholesterol refers to the cholesterol contained in foods you
eat.  Cholesterol is found naturally in all animal tissue, but it does not
occur in any plants.  Fatty meats, dairy products and eggs are the most common
sources of dietary cholesterol.  Cholesterol does not occur in fats made from
vegetable sources, like cooking oil, although some vegetable oils contain
other fats you should avoid.
     "Blood" cholesterol refers to the cholesterol circulating in your
bloodstream.  Your blood cholesterol level is affected by two things.  The
first is your genetic makeup (which determines how much cholesterol your body
produces).  The second is the amount of saturated fat and cholesterol in your
diet.  Generally, the body makes only about 80 percent of its cholesterol, and
the rest comes from the food we eat.  The liver processes dietary cholesterol
and saturated fats into the lipoproteins that make up your blood cholesterol
"profile".

KNOW YOUR CHOLESTEROL NUMBERS

     High blood cholesterol doesn't cause any symptoms.  The only way you can
know if your levels are too high is to have a simple blood test done by your
doctor or other qualified health professional.  All adults over the age of 20
should have their blood cholesterol tested every five years.  A sample of
blood is taken from your finger or arm and tested to determine the blood
cholesterol level.
     Four items get special attention.  These are the total amount of
cholesterol in your blood; the relative amounts of HDL (or "good" cholesterol)
and LDL (or "bad" cholesterol); and total serum triglycerides, which are the
most common type of fat in the body.
     TOTAL CHOLESTEROL:  The National Heart, Lung and Blood Institute has
classified total blood cholesterol levels into three groups:
     Desirable:  200 milligrams/deciliter or less
     Borderline high:  200-239 milligrams/deciliter
     High:  Over 240 milligrams/deciliter
     The results of your first cholesterol test may be confirmed with a second
one.  Generally, the higher your total cholesterol number, the greater your
risk for heart disease.  If your total blood cholesterol level is high, or if
you have additional risk factors for heart disease, you should have a
lipoprotein analysis done.  This will determine the LDL (low-density
lipoproteins) level in your blood.
     LDL CHOLESTEROL:  LDL is also classified into three groups:
     Desirable LDL:  200 milligrams/deciliter or less Borderline high LDL:
200-239 milligrams/deciliter High LDL:  Over 240 milligrams/deciliter If your
cholesterol numbers are borderline, your doctor will probably suggest that you
start on a cholesterol-lowering diet and have your cholesterol retested in a
year.  He or she may also recommend other lifestyle changes.  For example,
exercising, quitting smoking, and limiting alcohol and coffee consumption can
help reduce blood cholesterol levels and lower the risk of heart disease.  If
the LDL ratio is unusually high, your doctor may prescribe
cholesterol-lowering drugs to bring your blood lipids down to normal levels.
Your doctor also may recommend an aggressive approach if you have other risk
factors for coronary artery disease.

     ADDITIONAL RISK FACTORS

     When high blood cholesterol and certain other circumstances (such as
smoking or high blood pressure) are combined, the risk of coronary heart
disease is even greater.  For example, if your cholesterol level is in the
"high" category and you also have high blood pressure, your risk for coronary
heart disease is six times higher than that of someone without those
conditions.  If you also smoke, your risk increases more than 20 times!
     Besides high cholesterol, high blood pressure and cigarette smoking,
other risk factors for coronary heart disease include a family history of
coronary heart disease before the age of 55, diabetes, vascular disease,
obesity and being male.  Whether your cholesterol level is borderline or high,
you should make some changes in your diet to lower your level.  You should
also modify any additional risk factors.
     Of course, you can't change all of these risk factors--for example, your
sex, or your family's medical history.  If you have risk factors that you
cannot modify, that's all the more reason to work harder at changing the ones
you can--like quitting smoking, losing weight or lowering your blood pressure.
Your doctor may also prescribe additional treatments and regular cholesterol
monitoring.

CAUSES OF HIGH BLOOD CHOLESTEROL

     Several different factors can raise the level of cholesterol in your
blood.  While you can't alter things like your genetic heritage, your age, or
your sex, other factors can be controlled.  Most people can lower their
cholesterol levels with diet alone.
     DIET:  Among the factors you can control, diet has the largest effect on
your blood cholesterol levels.  Diets that are high in cholesterol, saturated
fats and excess calories are linked to high blood cholesterol levels.
Saturated fat raises your blood cholesterol level more than anything else you
eat.
     HEREDITY:  The genes you inherited from your parents also play a role in
determining your blood cholesterol level and can control your ability to lower
your level by diet.  A small number of people have an inherited tendency to
have a low cholesterol level; others have a genetic predisposition to high
levels.  If you have a generic disorder that contributes to high blood
cholesterol (hypercholesterolemia), then your parents, children, brothers and
sisters should also have their cholesterol checked.  Dietary modification is
important even if generic factors contribute to your high cholesterol levels.
     AGE AND SEX:  Cholesterol levels tend to rise with age.  In the United
States, men's cholesterol levels generally rise from about age 20 to age 50,
when they start to decline slightly.  In women, levels also start rising at
age 20, but they generally remain lower than men's until the time of
menopause.  After menopause, women's levels often increase to levels higher
than those of most men.  Pregnancy and certain oral contraceptives also can
increase blood cholesterol levels in some women.
     WEIGHT:  People who are overweight tend to have high total cholesterol
levels.  They also tend to have low levels of the "good" protective HDL
cholesterol.  A low-fat, low-cholesterol diet can help lower their total
cholesterol levels, and weight loss can improve the ratio of HDL cholesterol
in the blot.
     PHYSICAL ACTIVITY:  Regular exercise can help you control your weight and
lower your blood pressure--both important additional risk factors for coronary
heart disease.  In addition, aerobic exercise can increase your "good" HDL
cholesterol level.
     SMOKING:  Besides being an important additional risk factor for coronary
heart disease, smoking may also contribute to high cholesterol levels.  There
is evidence that smoking suppresses HDL levels; if you quit, the level of this
protective form of cholesterol increases.
     STRESS:  High cholesterol levels have been linked to stress, but it is
not clear if stress itself raises cholesterol levels.  One theory is that
tension may somehow stimulate the release of stored fat into the bloodstream.
Another explanation is that during periods of stress, people tend to eat more
foods that are high in saturated fat and cholesterol.
     MEDICATION:  Certain kinds of medications can raise your cholesterol
levels.  Be sure to let your doctor know of any medications you are taking, so
he or she can determine if they might be a factor.

DIETARY FATS:  THE GOOD, THE BAD, AND THE UGLY

     The kinds and amounts of fats you eat can have a greater impact on your
blood cholesterol than any single other factor.  To add to the confusion,
there are three different kinds of dietary fats.  Cholesterol and saturated
fats (those that are solid at room temperature) increase blood cholesterol.
Certain unsaturated fats may help lower blood cholesterol levels by helping
rid your body of LDL cholesterol.
     CHOLESTEROL:  Like humans, other animals also produce cholesterol.  It is
heavily concentrated in egg yolks and organ meats like liver, and it is also
found in meat, milk and other dairy products, poultry and seafood.  Only
animal products contain cholesterol.  It does not occur naturally in fruits,
grains or vegetables, although non-meat and non-dairy products can contain
high levels of fat.  Prepared foods, such as crackers or bakery goods, may
contain high-cholesterol ingredients, such as lard, eggs or butter.
     SATURATED FATS:  Cutting back on saturated fats is the single most
important dietary change you can make to lower your blood cholesterol levels.
The liver converts saturated fats from your diet into LDL ("bad" cholesterol).
These fats raise your blood cholesterol more than anything else in your diet.
One exception is stearic acid, contained in some low-fat spreads.  This fat is
technically saturated, but it does not appear to raise cholesterol levels in
the blood.
     Foods that are high in cholesterol also tend to be high in saturated fat.
Meat, butter, cheese, whole milk, cream and ice cream are high in both
saturated fats and cholesterol, for example.  Saturated fat also "hides" in
certain vegetable products.  Coconut oil, cocoa butter (found in chocolate),
palm kernel oil and palm oil are high in saturated fat.  These "tropical"
vegetable oils are used in many commercially prepared foods, including
cereals, baked goods (such as, breads, crackers, cakes and cookies), candies,
snacks, non-dairy creamers and whipped dessert toppings.
     Many manufacturers are replacing high-saturated-fat tropical oils with
healthier alternatives.  Check labels carefully when you shop to be sure the
food is low in saturated fats--not just cholesterol.  For example, non-dairy
creamers made with tropical oils may have more saturated fat than the dairy
product they replace.
     UNSATURATED FATS:  You should substitute unsaturated fats for saturated
fats whenever possible.  Unsaturated fats can help to lower your blood
cholesterol levels.  There are two types of unsaturated fat:  polyunsaturated
and monounsaturated
     MONOUNSATURATED FATS:  Olives, canola (rapeseed), peanuts and avocados
contain oils that are high in monounsaturated fats.  Several scientific
studies suggest that monounsaturated oils like olive oil lower LDL (or "bad")
cholesterol without lowering HDL (or "good") cholesterol.
     POLYUNSATURATED FATS:  This is the oil predominantly found in corn,
soybean, safflower, sunflower, sesame and cottonseed oils.  Foods containing
these oils are healthier than their saturated alternatives:  for example, corn
oil margarine instead of butter.
     OMEGA-3 FATTY ACID:  A special type of polyunsaturated fat, omega-3 fatty
acid, is found in fish, especially salmon and mackerel.  There has been a lot
of publicity that omega-3 fatty acid can protect you from heart disease.  The
scientific research is not yet conclusive, and large quantities of omega-3
fatty acids can be harmful.  Most doctors recommend that you put fish fat in
your diet by eating fish in its natural form, rather than by taking omega-3
fatty acid supplements.
     HYDROGENATED FATS:  Hydrogenation is a chemical process that makes
unsaturated fat more solid at room temperature.  Shortenings and margarines
are made of partially or totally hydrogenated fats--for example, hydrogenation
changes corn oil into corn margarine.  The problem is that hydrogenation
converts heart-healthy unsaturated fat into its heart-harmful saturated
counterpart.
     When buying margarine, look for products that list liquid oil or stearic
acid instead of hydrogenated oil as the first ingredient.
Partially-hydrogenated fats are preferable to completely hydrogenated ones.
Tub margarines are usually the best bet, but check the list of ingredients to
be sure.

EATING YOUR WAY TO A HEALTHY HEART

     The average American eats much more fat than the body needs to function.
We need only one to two teaspoons of fat a day, but most of us eat six to
eight teaspoons' worth.  Most people get between 40 percent and 45 percent of
their total daily calories from fat.  Ideally, according to nutrition experts,
you should limit total fat intake to 30 percent of your total daily calories,
with no more than 10 percent coming from saturated fat.  A bonus of a low-fat
diet is that it will help you cut calories as well.  Foods that are high in
fat are also high in calories, because fats have twice as many calories as do
either carbohydrates or proteins.
     CUT BACK ON FAT:  Eating saturated fat raises your cholesterol level more
than twice as much as does eating cholesterol itself.  This is probably
because saturated fat stimulates your body to produce more cholesterol.
Keeping track of the different kinds of fat can be confusing.  At first, just
concentrate on reducing the total amount of fat in your diet.
     EAT NUTRITIOUS, HIGH-FIBER FOODS:  You should also eat plenty of foods
that are high in complex carbohydrates, like cereals, whole grains, fruits,
and vegetables.  These foods provide you with important nutrients and they are
rich in dietary (soluble) fiber.  Dietary fiber can bind to and remove some of
the fat and cholesterol in your system.  A word of caution:  suddenly
increasing your fiber intake can cause digestive problems, including bloating
and gas, so add new fiber to your diet gradually.
     PREPARE FOODS HEALTHILY:  Even heart-healthy foods can be made less
healthy if they're improperly prepared.  Bake, broil, poach, steam or
microwave food instead of cooking it with oil, butter or cream.  Herbs and
spices, lemon juice, wine, low-fat yogurt, crushed tomatoes, and orange or
pineapple juice are just a few of the flavorings that can impart delicious,
non-greasy flavors to a variety of meats and vegetables.

TIPS TO MAKE YOUR DIET SUCCEED

     It's not easy to change ingrained eating habits.  Here are some tips on
making changes that you can live with.
     Make changes gradually instead of making drastic overnight changes that
will be hard to follow.  Instead, try changing one aspect of your diet at a
time.  For example, you might start by switching from whole milk to low-fat
dairy products.  The next step might be to substitute fish and poultry for red
meat, or to change your usual breakfast of bacon and eggs to cereal and fresh
fruit.
     Plan your meals and snacks ahead of time, and shop wisely.  Keep your
kitchen stocked with tasty low-fat foods so it's easy for you to follow your
diet plan.  Avoid buying foods you can't resist that aren't on your diet.  If
another member of the family insists on them, keep them in a separate cabinet
where they'll be "off limits" to you.
     Eat a well-balanced diet.  A wholesome diet means eating something from
each of the four food groups.  Many people think that a cholesterol-lowering
diet means they should cut out all dairy and meat products.  The problem is
that the calcium and protein these foods contain are vital to your health.
Instead of eliminating them, opt for small portions and low-fat forms.  For
example, use low-fat yogurt instead of sour cream, or a small broiled pork
chop instead of a big plate of spare ribs.
     Don't completely deprive yourself of the fatty foods you love, just limit
their intake.  Half a cookie tastes as good as two.  Budget your saturated fat
calories for the day so you can make choices about how to use them.  For
example, skip the grilled cheese sandwich for lunch and enjoy a bowl of ice
cream after dinner.
     When you eat out, look for low-fat dishes prepared the way you would cook
them at home--that is, baked, broiled, or poached.  Ask if the food comes with
a sauce--if it does, ask to have it served on the side.  Even if the menu Says
"no substitutions," most restaurants will give you skim milk instead of cream
for your coffee, cole slaw instead of french fries, and so forth.
     Get smart about nutrition.  Your doctor may have materials about a
low-fat diet, and your local library will have books on nutrition and health.
Local organizations such as the American Heart Association or your county
health department can also suggest sources of reliable information.
     Don't cheat on saturated fats.  An occasional indulgence won't hurt if
you stay within your total allowance, but regular excesses will do damage.
You may be able to fool yourself that you're staying within your limit, but
you won't be able to fool your blood cholesterol level.

THE LIFETIME APPROACH TO CHOLESTEROL CONTROL

     Effective cholesterol control requires lifestyle changes that you adopt
not just temporarily but for a lifetime.  The lifetime plan for a healthy
heart includes exercise, weight loss, stress control, and a diet that is low
in total fat and cholesterol and high in fiber and vital nutrients.  This plan
can be followed by every member of your family.  Healthier eating habits will
not only lead to healthier hearts but also protect you and your family against
cancer and other nutritionally related diseases.
     Besides cutting back on saturated fats and cholesterol, make sure you get
aerobic exercise on a regular basis.  Quit smoking and lose weight if you need
to.  Make these lifestyle changes gradually, one step at a time.  Don't try to
give up cigarettes, cut back on cholesterol and start an aerobic exercise
program all at once.  The goal is to make permanent changes that last a
lifetime.  An occasional taste of a favorite high-fat or high-cholesterol food
won't raise your blood cholesterol levels, but slipping back into your old
patterns will.
     The lifetime approach to cholesterol control also requires regular
monitoring of your blood cholesterol levels.  Everyone over age 20 should have
their cholesterol level checked; children's levels should be checked if either
parent has a genetic tendency toward high blood cholesterol.  If your blood
cholesterol levels are desirable, continue a good diet to prevent them from
rising, and have your cholesterol retested within five years.  If the levels
are borderline, start a cholesterol-lowering diet and have your levels
retested within one year.  If your levels are high, or if you have any
additional risk factors for coronary heart disease, your physician or other
health-care professional can advise you about an individualized program of
follow-up treatment based on your particular needs.


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     This booklet has been researched by Margot Embree Fisher, with Dr. Robert
DeMarco serving as contributing editor and medical consultant.  Though all the
information contained in this booklet is up to date as we go to press,
research in this field is ongoing.  Your physician is your first line of
defense against any disease and should be consulted for the answers to the
special questions that concern you individually.
ÿÿ
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The material contained here is "FOR INFORMATION ONLY" and should not replace 
the counsel and advice of your personal physician.  Promptly consulting your 
doctor is the best path to a quick and successful resolution of any medical 
problem.
