House Calls / Dr. Michael Schwartz

Cholesterol is a waxy, fat-like substance essential in maintaining healthy cells. Naturally produced by the liver, cholesterol helps manufacture all of our steroid hormones (e.g. estrogen, testosterone and cortisol) as well as Vitamin D. Furthermore, cholesterol is synthesized as bile acids which are needed for digesting fat. The body generally produces just enough cholesterol to carry out all these essential functions; however genetics and dietary indiscretion can elevate these numbers and have the potential to lead to many illnesses.

Cholesterol levels can be measured in the blood. A simple blood test after a 10 to 12 hour fast accurately measures natural cholesterol. Results comprise several different values. The total cholesterol measured includes low density lipoprotein (LDL), high density lipoprotein (HDL), and very low density lipoprotein (VLDL). LDL or "bad" cholesterol is responsible for the atherosclerotic plaques which clog the arteries. HDL or "good" cholesterol helps transport cholesterol back to the liver and works to remove plaque from the walls of these arteries. VLDL (rarely reported in the blood work) contains triglycerides (fats) and is associated with a higher risk of heart disease and stroke. Triglyceride levels are inversely proportionate to the HDL: The higher the triglycerides the lower the HDL. Thus, lowering triglycerides may improve outcomes by raising the protective HDL. High cholesterol levels may increase your risk of heart disease, stroke, peripheral vascular disease and even dementia. Therefore, it is important to maintain a higher ratio of HDL to LDL as this tends to correlate with lower incidences of these diseases.

Cholesterol levels can also be affected by other medications. For example, beta-blockers (a type of blood pressure medication), diuretics (water pills) and steroids (e.g. testosterone) are known to raise cholesterol levels.

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The first line of treatment is a low-cholesterol diet. Some foods are high in cholesterol. These include eggs, cheese, butter, milk, ice cream, shellfish, fried foods and processed meats. Unfortunately, even with a strict low-cholesterol diet, cholesterol levels may remain elevated due to genetic influences. In that event, other medical therapies may be necessary to lower these values.

Medical Treatment

Statins (e.g. Lipitor, Pravachol and Zocor) are medications which decrease production of cholesterol. They tend to lower LDL and triglycerides and slightly raise HDL. New studies indicate statins possess a unique property in that they reduce inflammation. This reduction in inflammation not only decreases the risk of heart disease and stroke, but may ultimately decrease the risk of certain cancers. Their main side effects, although uncommon, are muscle pains, fatigue, confusion and liver damage. These are monitored by your physician via a simple blood test.

Niacin (or Vitamin B3) has been shown to raise HDL, lower LDL and lower triglycerides. However, niacin can cause severe flushing and abdominal bloating. Recent studies have indicated that patients taking niacin have a lower risk of stroke, but no significant decrease in their risk of heart disease.

Fibrates (e.g. Tricor and Lopid) are more effective in raising HDL and lowering triglycerides than lowering LDL. They are often used in conjunction with the statin drugs to improve the overall cholesterol profile. Although these medications have been shown to decrease heart attacks, they do not seem to have a significant impact on mortality. Thus, they are rarely used alone as treatment for elevated cholesterol levels.

Bile Acid Sequestrants (e.g. Questran) bind with bile in the stomach thus causing a deficiency of bile needed for digestion. The liver needs to utilize cholesterol in order to make more, thereby lowering cholesterol levels. Common side effects include stomach bloating, heartburn and constipation.

Other Treatments

Exercise has been shown to lower LDL and raise HDL. Thirty minutes a day is recommended for the best results.

Red wine (in moderation) has been shown to reduce LDL levels and raise HDL. It has been suggested that resveratrol (an ingredient in red wine) may also reduce blood clotting. However clinical studies have yet to prove this.

Herbal supplements including red yeast rice, plant sterols, flax seed oil and soy have been shown to be effective in lowering cholesterol. However their effects on heart attacks and stroke prevention have not been proven.

Studies have revealed that lower cholesterol levels tend to be associated with better outcomes. However, cholesterol is just one of many risk factors for heart disease and stroke. Life style changes including a proper diet, weight control and exercise are all equally important in minimizing your risk. Preventative medicine is the key to health and longevity. Visit you doctor for a cholesterol test today. Lower your number and lower your risk.

Dr. Michael Schwartz is board certified in internal medicine with a private practice in Darien. For comments or questions, please visit his web site at