It’s not uncommon for people who’ve just suffered a heart attack to object to the idea of going on cholesterol medication when I make the suggestion. “I just saw my doctor last month. He said my cholesterol was fine.” Since the pathology of coronary atherosclerosis invariably involves cholesterol deposition into the lining of the artery, a person with a typical heart attack has, by definition, a dysfunctional balance of cholesterol. But I avoid verbalizing the thought that first comes to mind: Well, here you are in a hospital bed with a new stent in place. Clearly your cholesterol can’t be that great.
No, instead I try to educate my patient. Studies have repeatedly shown that people are more likely to remain compliant with their medications if a caregiver has taken the time to explain the nature of the illness and purpose of the drug. The problem comes when doctors provide conflicting advice (or, at least, seem to). How can a person with “normal” cholesterol 3 months ago all of sudden find themselves in the range where drug therapy is mandatory?
Here are some potential explanations:
- There are different levels of risk. The national guidelines on the treatment of cholesterol can be confusing. One of the problems lies in the way the expert recommendations have shifted over time. It seems that every few years we learn that cholesterol levels we previously thought to be normal are now falling in the “high” range.
Adding to the confusion is the fact that one person’s “normal” lipid level may be high for someone else. Take a moment to review the chartdocumenting our current guidelines. A healthy 24-year-old who doesn’t smoke can have an LDL (low-density lipoprotein) cholesterol of 150 mg/dL and not require therapy. For his father, on the other hand, a long-time smoker with a history of diabetes, an LDL of 150 mg/dL is dangerously high and warrants aggressive drug therapy to bring the number down to below 100 mg/dL.
Anyone with coronary disease automatically falls into the high risk category. Because of this, a heart attack survivor with an LDL of 130 mg/dL who was previously thought to be healthy could have heard from his primary doctor last month that his lipids don’t need treatment. Now that he’s in the intensive care unit and his disease has been fully investigated, a cardiologist is telling him just the opposite. Neither doctor is wrong (working with information available to them at the time) and both were following the same guidelines.
- There are many physicians (and I fall into this category) who hold to the notion that anyone with atherosclerotic vascular disease—such as heart attack, stroke and peripheral artery disease—should be on aggressive cholesterol medication regardless of their baseline lipid levels. There’s plenty of evidence to argue that even people with low LDL cholesterol who’ve had heart attacks will benefit from the use of statin medications (Lipitor, Crestor, etc.). A subset of the more than four thousands heart attack survivors who participated in the landmark 4S Study had low LDL levels prior to their diagnosis (at or below 100 mg/dL), yet these patients derived the same benefit from the use of simvastatin as those with high numbers. Thus, if you develop coronary artery disease, and if your doctor reads the current data as I do, you may end up on statin medication even if you’ve always been told your numbers look great.
- What is normal, anyway? I’ve previously written on the method we use to determine what constitute normal versus abnormal laboratory findings. We simply take a large sample of average people, tally their cholesterol levels, and call the middle 95% of them normal (for a discussion on this topic please see previous blog).
But is the average American—whose mean cholesterol level is 208 mg/dL, by the way—the same things as the average healthy American? Dr. James H. O’Keefe of the Mid America Heart Institute in Kansas City, MO, and an expert on lipids, argues that we humans are designed to thrive on cholesterol levels far below 208 mg/dL. In an essay published in the Journal of the American College of Cardiologyin 2004, Dr. O’Keefe suggests that we need to look to hunter-gatherer societies and our mammalian cousins to discover what the truly optimal lipid panel should look like.
The Kalihari tribein Africa, to bring up one example, subsists on a diet high in complex carbohydrates and lean proteins but very little fat. The average cholesterol level in those individuals is well under 150 mg/dL and, not coincidentally, the incidence of coronary atherosclerosis is correspondingly very low. Across the board, “less civilized” societies whose diet and lifestyle mimic early human experience (ie. the diet that our bodies evolved to thrive on) tend to have a combination of very low cholesterol level and extreme longevity. Even babies, who enter this world with an average LDL cholesterol of 30-70 mg/dL, give us some insight into what our normal level should be.
Mammals who share most of our DNA, such as primates, also do best with less cholesterol in their system. In fact (writes Dr. O’Keefe), “modern humans are the only adult mammals, excluding some domesticated animals, with a mean LDL level over 80 mg/dL and a total cholesterol over 160 mg/dL.”
Gorillas in captivity, by the way, die from old-fashioned coronary artery disease more than from any other malady (I would have thought that falling off New York skyscrapers is a more common cause of death among oversized monkeys), as learned the hard wayby the Cleveland Metroparks Zoo. The veterinarians at that facility diagnosed heart disease in their Western lowland gorillas, Bebac and Mokolo, brought on by the cholesterol-unfriendly commercial biscuits the primates had been fed for years. A switch to a more natural diet of vegetables and leafy greens has produced weight loss and improved cardiac function in the two middle-aged apes. Enhanced health wasn’t the only change zookeepers noticed when they discontinued the gorilla biscuits: “Another benefit of the diet is the complete eradication of a visually offensive habit that occurs in captive gorilla populations called ‘R and R,’ short for regurgitation and re-ingestion. It has not been observed in the wild and occurs among captives because of some element of the typical zoo diet.”
When he showed me this story, my fellow cardiologist and lipid expert Dr. Joseph Thibodeau remarked on what type of outrage might result among animal rights activists if we fed our zoo animals like we do ourselves. A daily diet of fast food and sugary sodas would legitimately qualify as animal cruelty.
The whole issue of cholesterol is plenty confusing without the sometimes mixed signals you receive from your doctors. Just bear in mind that what you’re hearing from the medical professionals, although it may seem contradictory, might be correct all around.
Besides, in the end the choice about how aggressively you treat your cholesterol comes down to your own preference. We do recommend, however, that if you decide to forgo our counsel to start a medication, you should see what you can do about joining your nearest Kalihari tribe or take up residence in the Cleveland Metroparks Zoo. Just steer clear of the gorilla bisuits—especially the used ones.