Lowering Cholesterol : CHD Risk Factors, Dietary and Drug Therapy

by Food and Drug Administration (FDA)

(Page 2 of 3)

Other CHD Risk Factors

In addition to total and HDL cholesterol levels, doctors take other CHD risk factors into consideration when determining how aggressively to treat high blood cholesterol. Age is a risk factor because CHD risk increases with age. An older person's risk is higher than that of a younger person, even when their cholesterol levels are the same. For men, age becomes a major risk factor at 45 years; for most women, at 55 years.

A family history of premature CHD is also a risk factor. Premature CHD is defined as heart attack before age 55 in a father or other close male relative, or before age 65 in a mother or other close female relative.

Other risk factors include cigarette smoking, high blood pressure, obesity, and diabetes. Although low HDL is a risk factor, an HDL level of 60 mg/dL or more is considered a "negative" risk factor- -that is, it protects against CHD.

Dietary Therapy and Lifestyle Changes

Dietary therapy is the mainstay of treatment of high blood cholesterol at every age. Unless a young adult (men under age 35, premenopausal women) is at very high risk of CHD, with a total cholesterol of more than 300 mg/dL, the NCEP recommends that drug therapy be delayed and dietary modification and lifestyle changes be attempted first. Moreover, even if a person with high cholesterol needs drug therapy, following an appropriate diet may add benefits, according to Denke.

Dietary therapy is prescribed in two steps, called the Step I and Step II Diets. These are designed to help reduce intake of saturated fat and cholesterol, and to help achieve a desirable weight by eliminating excess calories.

The Step I Diet is similar to the NCEP recommendations for the general public. The physician first tries to determine if the patient is already following the guidelines. If not, the Step I Diet is usually the starting point of dietary therapy. In the Step I Diet, no more than 8 to 10 percent of calories are in the form of saturated fat; 30 percent or less of calories come from total fat (saturated and unsaturated); and less than 300 mg of cholesterol are consumed each day.

The importance of lowering saturated fat intake should not be underestimated, according to Donald Hunninghake, M.D., professor of medicine and pharmacology at the University of Minnesota Hospital Center's Heart Disease Prevention Clinic and member of the NCEP expert panel. "A tremendous source of misinformation to the public is the emphasis by food companies that products such as vegetable oils contain no cholesterol; this plays on the consumer's recognition of cholesterol as a risk factor, but ignores the importance of saturated fat," he says.

The new food label, which lists amounts and percentages of total and saturated fat, as well as cholesterol, in a given food, can be used in planning palatable meals that meet the guidelines for the Step I and Step II Diets.

Also, FDA has authorized a health claim relating diets low in saturated fat and cholesterol to reduced risk of heart disease for foods that meet the criteria for being low in fat, saturated fat, and cholesterol and which do not contain disqualifying levels of sodium. (See "Starting This Month: Look for 'Legit' Health Claims on Foods" in the May 1993 FDA Consumer and "A Little 'Lite' Reading" in the June 1993 FDA Consumer.)

If the patient is already following the Step I Diet, or if this diet isn't adequate to lower cholesterol to desirable levels, then the Step II Diet should be tried, according to the NCEP report. People with high cholesterol who also have CHD or other atherosclerotic disease should begin immediately on this diet, with physician guidance. The Step II Diet calls for reducing daily saturated fat intake to less than 7 percent of calories and cholesterol to less than 200 mg. Since these requirements may demand some radical changes in the diet, assistance from a registered dietitian or other qualified nutrition professional may be helpful.

Overweight people can cut calories and increase physical activity under a physician's guidance to help lower total cholesterol, as well as lower the risk of developing other CHD risk factors, such as high blood pressure and adult-onset diabetes. Physical activity also raises HDL levels, further reducing CHD risk. Quitting smoking lowers the risk of developing CHD and other diseases, including emphysema and lung cancer.

The role of alcohol in the diet is controversial. "There is evidence that one or two drinks daily in men and one drink daily in women will raise HDL by 10 percent if a person has low HDL," says Stephen Scheidt, M.D., a cardiologist at New York Hospital-Cornell Medical Center in New York City. He defines one drink as a glass of wine, a can of beer, or a shot of scotch or other hard liquor.

But "alcohol has too many side effects to be used as a prescription to raise HDL," Denke cautions.

Drug Therapy

Drug treatment is considered appropriate for adults who have a high LDL level, especially if they also have other CHD risk factors, according to the NCEP report.

Bile acid sequestrants such as Questran and Questran Light (cholestyramine) and Colestid (colestipol) are approved for use in addition to dietary therapy in patients with high LDL levels who don't respond to dietary changes alone. Constipation is the most common side effect.

Niacin products such as Niacor and Nicolar, are approved for use in addition to dietary therapy in patients with high cholesterol levels or high triglycerides who do not respond adequately to diet and weight loss. Side effects, which may include flushing, itching, and upset stomach, limit its use in some people. There is some evidence that sustained-release niacin may be more likely to cause liver function abnormalities than conventional tablets, according to Hunninghake. He adds that people should not use niacin vitamin supplements to self- medicate.

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