By Dave Gardner
With health insurance rates perpetually rising, high cholesterol may have become the most mismanaged medical condition that science has rendered manageable.
According to the American Heart Association, cardiac-related disease accounts for 17 percent of total domestic health expenditures that are now exceeding $3.2 trillion. AHA also has found that as far back as 2010, heart disease inflicted $273 billion in direct medical costs, and projects that this total will reach $818.1 billion by 2030.
Alfred Casale, M.D., associate chief medical officer and chair of the Geisinger Health System Heart Institute, explained that there is no universal solution for cholesterol problems. Diet and lifestyle are usually involved, but the specifics of genetics may be at the root of some problems, with the patient unaware that there is a cholesterol problem until a cardiac event occurs.
Fortunately, careful screening of a patient’s blood cholesterol levels can reveal high-risk situations. Measurement of the blood’s high-density lipoprotein (HDL) level can shed light upon the body’s potential to suck up harmful blood fats and transport them away, while screening for low-density lipoprotein (LDL) can measure the body’s potential for carrying harmful fats in the blood and then dumping them onto the walls of blood vessels.
“When there is an imbalance between helpful HDL and harmful LDL levels, it often can be managed with lifestyle changes,” Dr. Casale said. “Medications can be used later if necessary.”
Cholesterol can be both a natural friend and an enemy to humanity. The liver naturally makes cholesterol, which is needed for health such as vitamin D synthesis.
In many cases, when the liver is behaving, control of LDL levels is at the fingertips of a patient. This is possible because lack of exercise, an improper diet, elevated blood pressure, stress, and a lack of sleep can all to some degree raise LDL levels, and are manageable.
“Of course, among manageable risks, tobacco remains the perfect driver for heart and circulatory illness,” said Dr. Casale.
Blood glucose levels also have been implicated in arterial disease. Dr. Casale explained that elevated blood sugar can actually injure blood vessel walls, and when an imbalance between HDL and LDL levels is added to the mix, a “double whammy” of trouble exists.
He described how a heart attack may result when fat with calcium becomes deposited upon the walls of an artery. Blood flow scrapes the vessel’s lining, the fissure becomes irritated, and blood gels in the irritation stopping the flow.
“Blood sugar, cholesterol and blood pressure all travel together,” said Dr. Casale. “When combined with smoking and a bad diet, you’re just begging for hardening of the arteries and blood clotting.”
Fortunately, for most patients with imbalanced cholesterol, risks can be lowered. Personal behavior conclusively affects healthy outcomes, and this must be acknowledged by the patient.
When this occurs, an initial “prescription” will include patronage at a fresh food “pharmacy” to alter eating habits, and a break with sedentary behaviors that can begin with walking within a parking lot and the use of stairs. Even modest exercise can generate significant improvements in cholesterol levels, and if age or arthritis deter activity, a simple walk after dinner can reap dividends.
“Extremist attitudes with cholesterol management are outdated,” said Dr. Casale. “This all is not rocket science. The key is to understand prevention is the best approach.”
A physician attempting to manage cholesterol problems must be clear with the patient about what is happening, and may probe that patient’s priorities. Together, the team must only set moderate and reachable goals, and use of education for motivation may be helpful.
“These resistant patients are urged to understand that their behavior affects more than just them,” said Dr. Casale. “They might be urged to control their cholesterol for their kids, spouse and grandchildren.”
In the event lifestyle and diet changes are not achieved or produce the needed results, drugs known as statins which lower blood cholesterol by curbing its production in the liver are an effective tool for physicians to use. These drugs can produce side effects which must be calculated versus the risk of heart attack or stroke, and this information must be shared with the patient.
“I’m sorry to say there still is a lot of illogical thinking out there when it comes to risks versus benefits with statins,” said Dr. Casale. “Sometimes it can be helpful for these patients to enlist a partner to help with behavioral therapy.”
Blood cholesterol levels clearly are actually surrogate markers that can predict a patient’s cardiac future, according to Linda Thomas-Hemak, M.D., president and CEO of The Wright Center for Graduate Medical Education. When a patient is already afflicted with cardiac disease, LDL levels below 70 are desired, with measurements lower than 190 for a healthy person and 130 the grand wellness prize.
“When these numerical goals are achieved we can prevent and potentially regress blockages,” said Dr. Thomas-Hemak. “This is why pharma intervention with a statin can be so important.”
Initially, she preaches the value of self-management, and educates her patients that body fat, cholesterol, diabetes and blood pressure are all interconnected and can amplify each other while changing metabolic functions. Therefore, the patient must take “ownership” of their health and delivery system, and direct their own destiny.
“Despite the power of self-management, there clearly is a genetic predisposition with some cholesterol problems,” said Dr. Thomas-Hemak. “I am a supporter of blood screening as early as age 9, and problem engagement very early on.”
In a frank admission, Dr. Thomas-Hemak stated that the traditional American lifestyle is very unhealthy. She therefore uses engagement to create an awakening in patients, which includes motivational interviewing to express empathy, deal with resistance, and develop patient autonomy plus mindfulness.
“Actually, cholesterol management involves quantity and quality of life issues,” said Dr. Thomas-Hemak. “It’s also true certain foods such as red yeast and Cheerios may help, so I will usually encourage patients to go this route and cope versus a quick jump to pharma solutions.”