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Cholesterol: How Low Can it Go?

By: Dr. Stefanie Kelley

"What is your particle size?" "How low are your LDL's?"
No, these are not the new pick up lines for the "over 65" crowd. These are the new questions in the trend to monitor cholesterol in adults more closely. No longer is monitoring cholesterol a concern for those 65 and over, high cholesterol is becoming a concern for adults starting at age 20, and even in children.

The National Cholesterol Education Program (NCEP) released the latest Adult Treatment Panel III (ATP III) which recommends more aggressive treatment of high cholesterol and identifies new levels of cholesterol as major risk factors for heart disease. Total cholesterol levels less than 200mg/dL continue to be desirable. High density lipoprotein (HDL) cholesterol is now recommended to be over 40mg/dL. The main change in the ATP III recommendations is that low density lipoprotein (LDL) cholesterol should be less than 130mg/dL or optimal LDL less than 100mg/dL. For more information on the ATP III at a glance go to www.nhlbi.nih.gov/guidelines/cholesterol/atglance.htm.

The elevation of low density lipoprotein (LDL) cholesterol is now a major risk factor for the development of coronary heart disease (CHD). Lowering LDL cholesterol is one of the main recommendations of the ATP III. This change focuses on lowering the low density lipids (LDL) cholesterol to:

	below 100mg/dL for persons with CHD
	below 130mg/dL for persons with 2 or more CHD risk factors
	below 160 mg/dL for persons with 0-1 CHD risk factors

The presence of clinical atherosclerotic disease that places a person at high risk for CHD includes: clinical CHD, symptomatic carotid artery disease, peripheral arterial disease, and abdominal aortic aneurysm. Major risk factors for CHD include:

	elevated LDL > 160mg/dL
	low HDL cholesterol < 40mg/dL
	cigarette smoking
	hypertension (BP > 140/90 mmHg) OR currently on antihypertensive medication
	family history of premature CHD (CHD in male first degree relative <55 years OR CHD in female first degree relative < 65 years)
	Age (men 45 years or older OR women 55 years or older)

The ATP III now recommends a fasting complete lipoprotein profile (total cholesterol, LDL cholesterol, HDL cholesterol, and triglycerides) as the preferred initial test. LDL cholesterol can be estimated using the Friedewald equation in which lab values are expressed in mg/dL:
LDL cholesterol = [Total cholesterol] - [HDL cholesterol] - [Triglycerides]/5. The complete lipoprotein analysis is suggested to be performed every 5 years for persons 20 years and older. If a person continues to be at low-risk for CHD, cholesterol screening can occur every 5 years. If CHD risk increases, the lipoprotein analysis is suggested to be a guide for clinical management. The ATP III does not make recommendations for cholesterol screening in children. However, the National Heart, Lung, and Blood Institute (NHLBI) recommends that children of "high-risk" families (parents with total cholesterol > 240 or a parent or grandparent that has CHD at 55 years or younger) should be screened.

As the LDL cholesterol takes on a greater concern for health care providers and patients, further understanding of the LDL measurement is important. The LDL cholesterol lab value is most accurate when the person has been fasting for 9 to 12 hours. The LDL lab value measures the amount of low density lipoproteins that carry cholesterol. This form of cholesterol has been found to cause athrosclerotic plaques in blood vessels that contribute to heart disease and stroke. The LDL measurement is a representation of a concentration of potentially athrogenic cholesterol particles, apolipoprotein B (apoB). These athrogenic particles can be small and dense OR soft and fluffy. The small and dense athrogenic particles are sticky and are thought to be more often associated with atherosclerosis than the large fluffy particles. Measuring the apoB is a newer method for predicting risk of developing heart disease. Knowing particle size could allow health care providers to initiate therapeutic lifestyle changes (TLC) early in order to prevent plaque formation. More information on measuring apoB can be found at www.americanheart.org/presenter.jhtml?identifier=3016380.

Clinical management of elevated cholesterol and LDL cholesterol requires multidimensional treatment. Initiating therapeutic lifestyle changes (TLC) is the first line treatment of elevated cholesterol. ATP III recommends the TLC Diet:

	Saturated fat <7% of calories, cholesterol < 200 mg/day
	Increased soluble fiber (10-25g/day) and plant stanols/sterols 2g/day

Saturated fats, which are the main dietary cause of high cholesterol, are found in animal foods (beef, veal, pork, poultry, and dairy products made from whole milk) and some plant foods (tropical (palm, coconut) oils and cocoa butter). Hydrogenated fats that raise cholesterol are found in most margarine and shortening. Use hydrogenated fats only if there are fewer than 2 grams of saturated fat per tablespoon. Polyunsaturated and monounsaturated fats may lower cholesterol and can be used in limited amounts in place of saturated fats. Weight management and increased physical activity are key components included in lifestyle changes. Drug therapy for lowering cholesterol should be considered if after 3 months there is no change in LDL levels or additional CHD risk factors are assessed.

The NCEP ATP III recommendations and continued efforts by researchers, health care providers, and patients represent the ongoing effort to reduce the morbidity and mortality of elevated blood cholesterol. As the body of knowledge on CHD increases cholesterol management continues to be a dynamic medical challenge.

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