Physician Dr. Rob Lamberts does a creative job of clearing up some confusing questions about cholesterol in his always enlightening “Musings of a Distractible Mind” and related House Call Doctor podcast at Quick & Dirty Tips.
He starts off by reminding us that the current protocols for treating high cholesterol date back to before he was practicing medicine.
“Some smart scientists had noticed that people with high cholesterol had a higher risk of heart attack. More scientists got together and decided that, based on the evidence, keeping a low cholesterol number was a good idea. To celebrate their decision, they went out to a dinner of bacon cheeseburgers and donuts.”
He goes on to explain, however, that early research showed that there are people with high cholesterol who don’t have heart attacks, whereas others with low levels do.
“This research showed that there are several types of cholesterol of varying density. They named these types of cholesterol High Density Lipoproteins (HDL), Low Density Lipoproteins, (LDL), and Very Low Density Lipoproteins, or VLDL (mostly composed of fats called triglycerides.”
High LDL is associated with higher risk of heart disease, while a high HDL is associated with a lower risk. LDL is commonly referred to as bad cholesterol, and HDL as good cholesterol. Dr. Rob muses:
“You have to wonder how long these politically-incorrect names will be used. LDL’s self-image must be shot by now with all the praised being heaped on HDL.”
However, back in the science lab, other scientists began to notice that even some people with high LDL didn’t develop heart disease, and some with low LDL did.
“I say this only to point out how annoying some scientists can get if they have time on their hands.”
What about the total cholesterol number that our doctors tell us about? Dr. Rob explains:
“Total cholesterol is calculated by using a formula that includes HDL, LDL, and triglycerides. That makes the overall cholesterol number of limited use to me as a doctor.
“It’s kind of like if you asked someone for the score of a football game and they answered ’42’ by adding together the scores of both teams. Technically, they are right in their answer, but the information is probably not what you want. You want to know the score of the good team and how it compares to that of the bad team.”
That’s why Dr. Rob believes that you need to know both your LDL and your HDL numbers, not just your total cholesterol levels. He warns:
“People don’t die from high cholesterol. They die from heart attacks and strokes. If I knew a person with high LDL cholesterol would stay healthy until they were 90, I wouldn’t bother treating them.”
He also offers some helpful tips, including:
- 1. Get your cholesterol checked
- 2. Don’t focus on the total cholesterol
- 3. Know your five other risk factors: high blood pressure, smoking, diabetes, strong family history of heart disease, and advanced age
- 4. Do what you can to have the lower LDL and higher HDL numbers: exercise, control your weight, eat right, don’t smoke
- 5. Consider cholesterol-lowering drugs (statins) ONLY if you are at increased risk for heart disease
Dr. Rob says that he uses cholesterol medications when he feels the risk of taking them is outweighed by the risk of not taking them.
“Studies have shown that bringing the LDL down with specific medications in high-risk people lowers the risk of heart disease and death. Which people and which medicines? That’s what I did all my training to know. You’ll need to see your own doctor to find out if these medications are appropriate for you.”
The question of who is considered “high-risk” has also been explored recently by researchers.
The British Medical Association journal, Lancet, published a study completed by Dr. John Abramson from Harvard Medical School and Dr. James Wright from the University of British Columbia that questioned prescribing statin drugs routinely for those with high LDL (bad) cholesterol but who were otherwise at low risk for developing heart disease. Here’s what they wrote:
“Statins do help those aged between 30 and 80 who already have established heart disease, and for them their use is not controversial.
“But we found no clear evidence that statins work as a primary heart disease prevention tool for otherwise healthy women, or for men over the age of 69.”
Dr. Scott Grundy from the University of Texas claims that trials involving both men and women at moderately high risk have shown overall risk reduction from cholesterol lowering therapy, but not enough women were included to provide a definitive result. He warned:
“Until a large-scale clinical trial is carried out to test the efficacy of cholesterol lowering in women at moderately high risk, drug therapy should be avoided in most lower risk women. But in those who have multiple cardiovascular risk factors and who are projected to be at moderately high risk, use of statin drugs should not be ruled out.”
But UK physician Dr. Malcolm Kendrick believes the evidence of benefit is not strong enough. He points out that, to date, none of the large prevention trials has shown a reduction in overall mortality in women, and one even suggested that overall mortality may actually be increased.
This, he says, raises the important question whether women should be prescribed statins at all. Some studies also suggest that statins carry a substantial burden of side effects.
Speaking of cholesterol drugs, Dr. Rob Lamberts doesn’t believe they’re dangerous, but agrees that they may carry significant risks.
“That’s why I have to have a license to prescribe them, and why they aren’t in the grocery store next to the candied yams. All drugs should be used only when the benefit significantly outweighs the risk.”
What are current recommended cholesterol readings? Depending on other risk factors you may also have, Health Canada recommends the following cholesterol target goals:
- Total cholesterol: < 5.2 ( > 6.2 = too high)
- LDL (bad) cholesterol: < 3.5 ( > 4 = too high)
- HDL (good) cholesterol: > 1
For Americans, units for cholesterol levels are mg/dL while in Canada, we use mmol/L. The rough conversion factor is 40. To convert from American to Canadian units, just divide by 40. Find out more about good, bad and ugly cholesterol from the College of Family Physicians of Canada, or watch this one-minute video.
Learn more from Dr. Robert Lamberts at Quick & Dirty Tips.
- Women and statins: evidence-based medicine or wishful thinking?
- Women, controversial statin guidelines, and common sense
- Study: Statin Drugs Over-Prescribed for Healthy Adults
- Women at Greater Risk for Side Effects When Taking Statins
- Can statins prevent my head from exploding?*
- Statin guidelines we love to hate – and the docs who write them*
- Universal Cholesterol Screening for Little Kids?*
- How Merck Got Us to Spend $21 Billion On Drugs That Don’t Work*
* from my other site, The Ethical Nag: Marketing Ethics for the Easily Swayed