It started with eggs. Egg whites became the rage. “Heart Healthy” appeared on packages. Lowering your cholesterol seemed directly linked to saturated fat. It was the 1990s. Actively involved in the integrative medicine community in the Bay Area at the time, I listened to several talks by Dean Ornish M.D., who was reversing heart disease with a plant based diet.

Fast forward. It is 2017. Paleo and primal eating are the rage. Fat is back in, in large amounts. People have steered toward a protein rich low carb diet, and guess what? Some people lower their cholesterol that way.

It turns out that the story between your cholesterol, particularly the LDL cholesterol and your diet (including fats and carbs) is a much more complicated story than we thought 20 years ago.

When I was in my training we were taught to monitor cholesterol and get people to their “goal” LDL (the “dangerous cholesterol”). If you had had a stroke, a previous heart attack or diabetes your goal was under 70. For most people optimal was 100-130. If you had risk factors: family history of a male with a heart attack below 45 or a female with heart attack below 55 we wanted you lower than 130. If you were a smoker or had high blood pressure we wanted you below 130. If you had a good level of good cholesterol, we subtracted a point on your scale of risk factors. If you were older than 45 as a male or 55 as a female you were losing your protective traits of youth and your risk went up. It was a simple, mathematical calculation of goals. If there were no risk factors your LDL could be as high as 160 to 190 before physicians were talking medication management.

A few years ago there was a major over haul of this approach. The cardiovascular specialists were trying to make sense of people that had “good” cholesterol numbers, but still died of heart attacks. Or the ones with “bad” LDL numbers and lived many years, sometimes unmedicated.

To address this Doctors developed an algorithm and put out a calculator called the ASCVD risk estimator, taking into effect the big risk factors we know effect heart disease: age, high blood pressure, smoking and diabetes. They worked to move physicians away from a number-driven approach for LDL goals and instead wanted us to focus on the estimated percentage risk for heart disease over a ten year period. They determined that on the ASCVD risk calculator, anyone with greater than a 5% risk of having a heart attack in the next 10 years should be on a statin medication.

That is when the controversy came. Since the ASCVD risk calculator came out, I have determined the risk percentage with every cholesterol reading I’ve taken. One day I realized that it was over 5% in Caucasian males over 55 so often that, according to the guidelines, I should be recommending statins regularly.

So I decided to play with the values. I attempted to make the perfect 55 year old Caucasian male. One that was 55, with HDL (good) cholesterol as high as the calculator would let me guesstimate, total cholesterol 150 (very low), and of course a non smoker, non diabetic, and non hypertensive. That imaginary person didn’t get the recommendation for a statin. Practically everyone else did.

I was not the only practitioner that held this grievance with the risk based approach. It seems, with 5% as the threshold, the risk for heart disease for any man over 55 or woman over 65 is so high that we might as well put statin medications in the water.

Luckily, the cardiologists have moved the mark and now 7.5% is an acceptable risk before medication is deemed necessary. Good thing, because I have been letting healthy five percenters off the hook for years.

The truth is, science continues to understand more and more about the complexity of cholesterol and heart disease. We now know there are dangerous forms of your LDL and less dangerous forms. There are attributes we can measure on your HDL to see if it is capable of doing its job to sweep up the cholesterol out of the plaques in your arteries (that is what makes it good). There is a role of inflammation, and we have markers in blood work we can follow to see if you are at risk for heart disease based on inflammation or inherited types of dangerous LDL known as Lp(a). For years I have referred to this testing as “fancy cholesterol” tests. Indeed, they cost more money but the value of further dissecting your risk is worth it in my mind.

Not everyone needs a fancy cholesterol test. However, if your cholesterol is high or you have the major risk factors (family history of early heart attack, smoking, diabetes, high blood pressure) you should talk with me about getting the in depth test at least once. We can even find out if you are someone who is more likely to respond to diet changes or if you are more genetically susceptible to getting a side effect front the statin medications.

Many people come to me because I try to manage cholesterol holistically as often as possible, and I do not force statin medications on patients that do not want to take them. I do see a role for these medications. They stabilize plaques, reduce cholesterol numbers effectively, and decrease inflammation in your arteries. I also recognize that medications have risks, and statins (Lipitor, etc) are no exception. There is a time and place for everything and sometimes we need this tool.

However, if you want to manage your cholesterol on your own, without a statin, I can help! I have been studying effective alternatives for years and actively use a variety of supplements and lifestyle changes to modify cardiovascular risk. We can do a Calcium Score, which is a coronary (heart) artery cat scan that helps us know if you have evidence of current heart disease. With this test, we can decide together if your risk of heart disease is high enough that you need the traditional medications, or if we have room to try some of the alternative options.

Stay tuned over the next several weeks for highlights from some of my favorite options for an alternative management of cholesterol. But please, don’t stop any medications without consulting your doctor. If you aren’t seeing me now, think about joining the practice or coming for a consultation on this issue so we can decide together the best approach for you. At the end of the day, personalized medicine is best, and I want to make sure we get this right.

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