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Harvard Commentaries
Harvard Commentaries
Reviewed by the Faculty of Harvard Medical School

Man to Man Man to Man

Lower the 'Bad' Cholesterol for Your Own Good

January 24, 2013

By Harvey B. Simon M.D.

Harvard Medical School

Last month, I discussed atherosclerosis and the risk factors for coronary artery disease . Cholesterol is near the top of the risk-factor hit list, which is why it's the topic for Man to Man this month and next. For all its notoriety, though, cholesterol is often misunderstood.

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The Truth About Cholesterol

Misconceptions about cholesterol begin with its very nature.

  • Most people think of cholesterol as a fat, but it's actually a sterol, a waxy, fat-like substance that has a chemical structure not found in true fats.
  • Cholesterol has a reputation strictly as a health hazard when, in fact, it's essential for good health. It's the building block of cortisol and all other steroid hormones. Without cholesterol, men wouldn't have testosterone and women wouldn't have estrogens.
  • People assume that the cholesterol in their blood only comes from the cholesterol in food they eat. In fact, about two-thirds of the cholesterol in your blood is made by your liver. Dietary cholesterol does contribute to the remaining third. But it's actually fats in food that prod the liver to make more cholesterol, which then pours into the blood.
  • There's the idea that some cholesterol is good while some is bad. In fact, there is only one type of cholesterol. The cholesterol in an egg yolk is exactly the same as the cholesterol your body uses in your brain cells, turns into testosterone, or packs into an artery-blocking plaque. But like many misconceptions, this one begins with a very important truth: Instead of floating free in your blood, cholesterol latches onto blood proteins that carry it through your body. The ones that are familiar to most people are low-density lipoproteins (LDL) and high-density lipoproteins (HDL). They determine the fate of the cholesterol in your blood.

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Know Your Number

LDLs deposit their load of cholesterol just where it will do the most harm — in the walls of your arteries. That makes LDL cholesterol the "bad" cholesterol. But where a villain lurks, a hero can be found. In this case it's the HDLs, which snatch cholesterol away from artery walls. HDL cholesterol is very good indeed. (More about that next month.)

Many years ago, scientists discovered that high LDL cholesterol increases a person's risk of heart disease. But it took major studies over the past 12 years to prove that lowering LDL cholesterol is truly beneficial. And recent research shows that very low levels are best for people who already have cardiovascular disease or other high-risk conditions. Here are the latest LDL numbers to aim for.

Heart Disease Risk Categories

Recommended LDL Goals

Optional LDL Goals*

Very High Risk:
People with acute coronary artery syndrome (heart attack or ongoing angina episodes)
Below 70 mg/dL
High Risk:
People with mild or stable angina, atherosclerosis, diabetes, hypertension or multiple cardiac risk factors**
Below 100 mg/dL
Below 70 mg/dL
Moderate Risk:
People with 2 or more cardiac risk factors**
Below 130 mg/dL
Below 100 mg/dL
Low Risk:
People with 0 to 1 cardiac risk factors**
Below 160 mg/dL
Below 130 mg/dL

*Some people may benefit from LDL goals that are lower than the recommended ones.

**Risk factors include cigarette smoking, high blood pressure (over 140/90 mmHg or on treatment), low HDL cholesterol (under 40 mg/dL), a family history of premature coronary artery disease in a parent or sibling (below age 55 in a male, 65 in a female), and age (over 45 in men, 65 in women).

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Ways To Lower LDL

Aiming low is one thing, but getting there is quite another. To get your LDL cholesterol into a safe range, you'll need to make some changes in these areas:

1. Diet

Eating less cholesterol may only have a modest effect on lowering your LDL, but every little bit helps. Limit your dietary cholesterol intake to about 200 mg a day — about the amount in a single egg yolk. Go easy on animal foods such as red meat, whole-milk dairy products and the skin of poultry. Animal products are the main source of saturated fat, which stimulates cholesterol production by your liver. So limit your saturated fat intake to less than 7% of your total calories.

Even more important is to avoid the trans-fatty acids found in stick margarine, many commercially baked goods, fried foods, and snack ("junk") food. But don’t skimp on the mono- and poly-unsaturated fats found in olive oil, canola oil, nuts, and fish. In fact, the omega-3 polyunsaturates in fish protect against heart disease.

Some foods can actually help lower your LDL. Topping the list is the soluble fiber found in oats, barley, beans, oranges, apples, and psyllium (sold as a fiber supplement). The plant stanols and sterols in spreads such as Take Control and Benecol can also help.

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2. Exercise

Exercise is essential for good health and may help lower LDL for some people. Set aside 30 minutes a day for moderate exercise such as brisk.

3. Weight Control

Weight loss is a powerful way to lower your LDL cholesterol. The key to success is cutting down on the calories you eat and ramping up the calories you burn with exercise. There is no other way. Calories do count. Period.

4. Tobacco

Don't smoke or use tobacco. No two ways about this one, either. Enough said.

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5. Medication

Lifestyle is important, but nearly everyone who needs to lower their LDL level to 100 mg/dL or less also needs medication.

The statin drugs have been the star weapon of the past decade. Nothing else comes close to doing the job of reducing LDL cholesterol levels. And new research shows the statins do even more to improve vascular health. They fight inflammation in the arteries, stabilize cholesterol-laden plaques, improve the function of the endothelium (the arteries’ inner lining), and help prevent the formation of artery-blocking clots. And with the notable exception of cerivastatin (Baycol), which was taken off the market in 2001, the statins have proved quite safe.

Like all medications, however, the statins must be used with care. And if patients can't tolerate them because of side effects or if they need extra help — other types of drugs, such as ezetimibe (Zetia), are available. There are six statins on the market, which can lower LDL cholesterol by 20% to 60%:

  • Lovastatin (Mevacor)
  • Pravastatin (Pravachol)
  • Fluvastatin (Lescol)
  • Simvastatin
  • Atorvastatin (Lipitor)
  • Rosuvastatin (Crestor)

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Harvey B. Simon, M.D. is an Associate Professor of Medicine at Harvard Medical School and a member of the Health Sciences Technology Faculty at Massachusetts Institute of Technology. He is the founding editor of the Harvard Men's Health Watch newsletter and author of six consumer health books, including The Harvard Medical School Guide to Men's Health (Simon and Schuster, 2002) and The No Sweat Exercise Plan, Lose Weight, Get Healthy and Live Longer (McGraw-Hill, 2006). Dr. Simon practices at the Massachusetts General Hospital; he received the London Prize for Excellence in Teaching from Harvard and MIT.

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