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Cholesterol and Your Risk of Heart Disease

Cholesterol is a waxy substance that occurs naturally in all parts of the body. Your body needs cholesterol, which it uses to make many hormones and vitamin D. Cholesterol is also involved in producing bile acids, which help the body process the fats you eat. Your body produces enough cholesterol to meet its needs.

How High Blood Cholesterol Leads to Heart Disease

When there is too much cholesterol in your blood, the excess can become trapped in the walls of your arteries. By building up there, the cholesterol helps to cause hardening of the arteries or atherosclerosis. And atherosclerosis causes most heart attacks. How? The cholesterol buildup narrows the arteries that supply blood to the heart, slowing or even blocking the flow of blood to the heart. So, the heart gets less oxygen than it needs. This weakens the heart muscle, and chest pain (angina) may occur. If a blood clot forms in the narrowed artery, a heart attack (myocardial infarction) or even death can result.

Cholesterol buildup happens very slowly - you are not even aware of it. If you lower your high blood cholesterol level, you can slow, stop, or even reverse the buildup - and lower your risk of illness or death from heart disease.

"Good" and "Bad" Cholesterol: The Lipoproteins

Cholesterol travels in the blood in packages called lipoproteins. Just like oil and water, cholesterol and blood do not mix. So, in order to be able to travel in the bloodstream, the cholesterol made in the liver is also coated with a layer of protein making a lipoprotein. This lipoprotein then carries the cholesterol through the bloodstream.

Two types of lipoprotein affect your risk of heart disease.

• Low-density lipoproteins (LDLs): the bad cholesterol. LDLs carry most of the cholesterol in the blood, and the cholesterol and fat from LDLs are the main source of dangerous buildup and blockage in the arteries. Thus, the more LDL-cholesterol you have in your blood, the greater your risk of heart disease.

   

• High-density lipoproteins (HDLs): the good cholesterol. HDLs carry some of the cholesterol in the blood, but this cholesterol goes back to the liver, which leads to its removal from the body. So HDLs help keep cholesterol from building up in the walls of the arteries. If your level of good cholesterol is low, your risk of heart disease is greater.

What Makes Blood Cholesterol High or Low

Why do some people have too much cholesterol in their blood? Many factors help determine whether your blood cholesterol level is high or low. The following factors are the most important:

Heredity. Your genes partly determine the amount of cholesterol your body makes, and high blood cholesterol can run in families.

Diet. Two nutrients in the foods you eat make your blood cholesterol level go up: saturated fat, a type of fat found mostly in foods that come from animals; and cholesterol, which comes only from animal products. Saturated fat raises your cholesterol level more than anything else in the diet. Reducing the amounts of saturated fat and cholesterol you at is an important step in reducing your blood cholesterol levels.

Weight. Excess weight tens to increase your blood cholesterol level. If you are overweight and have a high blood cholesterol, losing weight may help you lower it.

Physical activity/exercise. Regular physical activity may help to lower LDL-cholesterol and raise HDL-cholesterol levels.

Age and sex. Before menopause, women have total cholesterol levels that are lower than those of men the same age. Pregnancy raises blood cholesterol levels in many women, but blood cholesterol levels should return to normal about 20 weeks after delivery. As women and men get older, their blood cholesterol levels rise. In women, menopause often causes an increase in their LDL-cholesterol level. Some women may benefit from taking estrogen after menopause, because estrogen lowers LDLs and raises HDLs.

Alcohol. Alcohol intake increases HDL-cholesterol. However, doctors dont know whether it also reduces the risk of heart disease. Drinking too much alcohol can certainly damage and liver and heart muscle and cause other health problems. Because of these risks, you should not drink alcoholic beverages to prevent heart disease.

Stress. Stress over the long term has not been shown to raise blood cholesterol levels. The real problem with stress may be how it affects your habits. For example, when some people are under stress, they console themselves by eating fatty foods. The saturated fat and cholesterol in these foods probably cause higher blood cholesterol, not the stress itself.

In addition to a high LDL-cholesterol level and a low HDL- cholesterol level, other factors also increase your chance of heart disease. The chart below lists these risk factors. The more of them you have, the higher your chance of developing heart disease. If you have any of these risk factors in addition to your high blood cholesterol, your risk of heart disease is even greater.

In addition to the risk factors on the chart, another factor that influences your risk of heart disease is where your body stores excess fat. If you have an apple-shaped body with most of your fat around the stomach, you are at a greater risk of heart disease than if your body is pear-shaped, with most of your fat around your hips. Generally, men carry their fat around the stomach, while women carry it on the hips and thighs.

Talk to your doctor about all of your risk factors and what you can do to reduce your chance of heart disease. Often, the actions you take to control one risk factor help reduce others as well. For example, losing weight helps to reduce your blood cholesterol levels and high blood pressure, and helps to control diabetes. Regular physical activity can help you lose weight as well as improve the fitness of your heart and lungs, which also can help lower your risk of heart disease.

What Your Blood Cholesterol Levels Mean...
If You Do Not Have Heart Disease

"Why Should I Worry? I've never been sick a day in my life."

Even if you dont now have any signs of heart disease, it doesn't mean you never will. Now is the best time for prevention. Otherwise, a high blood cholesterol level, as well as other risk factors, can lead to problems in the future.

Your Blood Cholesterol Tests

Blood cholesterol levels are measured in a small blood sample taken from your finger or your arm. The blood is tested for total cholesterol and, if accurate results can be obtained, HDL- cholesterol levels. You do not have to fast or do anything special before having this blood test. Depending on the results, you may also need a second blood test, a lipoprotein profile, to determine your LDL-cholesterol level; you do have to fast for this test. An LDL-cholesterol level gives the doctor more information about your risk of heart disease and helps to guide any necessary treatment.

Check Your Level

After the test, compare your results with the levels listed in the chart below. Refer to Chart 2 to see what your next steps should be.

Chart 1
Classification: Total and HDL-Cholesterol*

*For anyone 20 years of age or older

Chart 2
Classification: Total and HDL-Cholesterol*

What Your LDL-Cholesterol Levels Mean

A high LDL-cholesterol level increases your risk for heart disease. Use Chart 3 below to find out about your risks and your next steps.

Chart 3
Classification: LDL-Cholesterol

Profile - Jack Williams Story

Risk Factors
Jack is 35 years old, and his father died from a heart attack at the age of 50. Jack smokes about half a pack of cigarettes a day. His diet is high in saturated fat, cholesterol and calories. He is not physically active. His doctor ordered a lipoprotein analysis, and the results are shown below:

Lab Report

Total cholesterol	260 mg/dL
HDL-cholesterol	40 mg/dL
LDL	190 mg/dL

Evaluation
Jack is at a high risk for heart disease. Heres why:

• He has a family history of early death from heart disease.

• He smokes.

• His total cholesterol and LDL-cholesterol levels are high.

• He is physically inactive.

Reducing Risk
The doctor identified Jack as being at a high risk for heart disease. She advised him to stop smoking. Jack had tried to stop on his own, but never quit for more than a few weeks. This time, he enrolled in a program at work that charges him for each class. But if he stops smoking, he will get his money back. His health insurance premium also will go down.

The doctor wanted Jack to focus on giving up smoking. She said that changes in his eating and activity could wait. However, she told him to eat fewer fried foods and more breads, fruits, and vegetables. She said he should get at least some physical activity and suggested that he part further away when shopping at the store, work in his garden, and use the stairs more often.

Two months later, Jack had quit smoking. But he still attended the smoking classes so that he wouldn't start again. The doctor said he was ready to start a Step I diet to improve his blood cholesterol levels, and she told him how to follow it. If Jack had high blood pressure, he would have been advised to follow a low-sodium Step I diet. The doctor also suggested he try to walk about 5-10 minutes in the evening after work, a few days a week.

3 months later his blood cholesterol levels were:

 

Lab Report	3 months ago	Today
Total cholesterol	260 mg/dL	224 mg/dL
HDL-cholesterol	40 mg/dL	45 mg/dL
LDL	190 mg/dL	149 mg/dL

Jack's progress pleased his doctor, but his levels were still not low enough. The doctor told him to walk briskly for 10-15 minutes three times a week and to add more time each week until he reached a 30 minute walk. She also put him on a Step II diet and referred him to a registered dietitian (R.D.) to help him follow it. After 1 month on the diet, he could follow it at home but not when eating out. He went back to the dietitian to get more tips to help him follow the diet when eating out.

After 3 months on the diet, Jack's blood cholesterol levels had fallen to the desirable range. His wife also liked the diet and has modified family recipes, as well as tried new ones for the whole family to enjoy. Now when Jack eats out, he asks about how a food is cooked to be sure it fits into the diet. His new food habits have become a part of his way of eating and his family's.

Jack also walks 30 minutes, three or four times a week. He hasn't smoked a cigarette since joining the class at work, and he still attends the class once a month. He feels great and has lots of energy. He plans to stick to his new habits and keep his cholesterol levels down and reduce his risk of heart disease.

What Your Blood Cholesterol Levels Mean...
If You Do Have Heart Disease

"I already have heart disease -- isn't the damage already done?"

Its not too late to help your heart. In fact, if you already have heart disease, you should pay even more attention to your cholesterol level. You have even more to gain. A person with coronary heart disease has a much greater risk of having a future heart attack than a person without heart disease. If you lower your blood cholesterol level, you can definitely reduce your risk of future heart attacks and may, in fact, prolong your life.

Your Blood Cholesterol Tests

Since you have heart disease, finding out your blood cholesterol level is a little different. You will need to have a blood test called a lipoprotein profile. This test will determine not only your total and HDL-cholesterol levels, but also your LDL-cholesterol leveland levels of another fatty substance called triglyceride described on the next page. In order to take the test you must fast. That means you can have nothing to eat or drink but water, or coffee or tea with no cream or sugar for 9-12 hours beforehand.

Check Your Levels

Since you have heart disease, your doctor will use your LDL- cholesterol level to decide on the best treatment. Your aim should be to have a LDL-cholesterol level lower than that of people who do not have heart disease. Compare your levels to those in the Chart 4 to find out what your next steps should be.

Chart 4

Profile - Betty Johnsons Story

Risk Factors
Betty is 60 years old and his a history of chest pain for which she has had tests and which her doctor diagnosed as angina. She is about 35 pounds overweight. She is not physically active. She has no family history of heart disease.

Lab Report

Total cholesterol	240 mg/dL
HDL-cholesterol	30 mg/dL
LDL-cholesterol	175 mg/dL
Triglycerides	180 mg/dL

Evaluation
Betty has a high risk for having a heart attack. Heres why:

• She already has coronary heart disease

• Her total blood cholesterol and LDL-cholesterol are high

• Her HDL-cholesterol is low

• She is overweight

• She is physically inactive

Since Betty has established coronary heart disease and high total and LDL-cholesterol levels, the doctor decided to try the Step II diet. he asked her what she usually eats and found that her diet is high in saturated fat, cholesterol, and calories. She eats out often and likes to cook and eat big meals with her family. The doctor told her how to gradually change what she eats in order to follow a Step II diet that is also low in calories and how it could help her to lose weight.

After talking to the doctor, Betty tried making changes in what she ate for a few days, but then she stopped, not wanting to bother with it. She did not make any changes that would reduce the saturated fat, cholesterol, and calories in her diet. Three months later Betty had a heart attack.

Reducing Risk
After her heart attack, the doctor asked Betty whether she would follow the Step II diet or preferred to try taking medicine. Betty promised herself and the doctor to follow the Step II diet. She began to eat smaller portions; choose items lower in saturated fat and cholesterol such skim milk and low-fat dairy products instead of the full-fat varieties; and baked her foods more often using herbs and spices. Because she has heart disease, she started with a low-calorie, Step II diet. When she returned to the doctor,s office 2 months later, she had lost about 8 pounds. But her total and LDL-cholesterol levels were still too high.

 

Lab Report	2 months ago	Today
Total cholesterol	240 mg/dL	216 mg/dL
HDL-cholesterol	30 mg/dL	37 mg/dL
LDL-cholesterol	174 mg/dL	149 mg/dL
Triglycerides	180 mg/dL	150 mg/dL

The doctor felt that she needed more help on her diet, so he referred her to a registered dietitian for help. He also told her to begin a morning walking program at the local mall and build up to walking 20-30 minutes, three or four times per week.

In 3 months, Betty lost another 10 pounds and felt better. She was walking three times per week and following the Step II diet most of the time. She ate out less often and used the Step II guidelines in cooking for her family.

Betty followed the Step II diet and was more physically active. Her blood values were getting close to her goals.

 

Lab Report	5 months ago	3 months ago	Today
Total cholesterol	240 mg/dL	216 mg/dL	205 mg/dL
HDL-cholesterol	30 mg/dL	37 mg/dL	40 mg/dL
LDL-cholesterol	174 mg/dL	149 mg/dL	135 mg/dL
Triglycerides	180 mg/dL	150 mg/dL	150 mg/dL

But, since her LDL level was still too high (greater than 130 mg/dL), the doctor decided to put her on a low dose of medicine. He explained how important it was for her to continue her new eating, exercising, and weight loss habits, even while taking the medicine. That way she could take a lower dose. Betty took the medicine, continued following the Step II diet, and exercised four times a week. Two months later, her blood cholesterol levels reached their goals. Betty is determined to keep up her good work and not to have another heart attack.

National Heart, Lung, and Blood Institute

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