]]]]]]]]]]]]]]]]       CHOLESTEROL AND YOUR HEALTH        [[[[[[[[[[[[
                         From the Newsletter of           (10/30/1989)
                         Thomas A. Dorman, M.D.
                          (Freeman 93401DORM)

       The first thing to understand is that fats are part of us. The 
lipids, as they are called scientifically, contain not only components 
which cannot be manufactured by the bodyUs own metabolism, such as 
some of the unsaturated fatty acids, which are the equivalent of 
vitamins in this sense, but also cholesterol, which allows the cell 
membranes to separate the cells from the surrounding milieu. The 
molecule is a chimera between water soluble and fat soluble. This 
mechanism also allows the fat to travel in the blood in little 
packets, which are analogous to those in the dish water after you have 
cleaned your frying pan with detergent.
       Nonetheless, as we have all been reading and seeing on TV, 
there is a national blitz on cholesterol. There is no doubt regarding 
an association between having a very high blood cholesterol and early
degeneration of arteries, atherosclerosis, which is the process 
responsible for most heart attacks and strokes. An association does 
not mean it is the cause. Families who have very high levels do have 
an increased incidence of artery disease and benefit from reducing the 
level by medical (pharmacological) means. Doctors and pharmacies get 
more business from mass fear. How can you determine if you have a 
problem?
       First it is important to get the order of importance into 
perspective. If you smoke, drink, fail to take regular exercise, have 
diabetes which is poorly controlled, or have high blood pressure, you 
would want to look after these problems long before worrying about 
your cholesterol. Now, if after all that you want to worry, you need 
to understand that TcholesterolU is sometimes used as an over-
simplification for what is better defined as a profile of the blood 
lipids; i.e. the composition of all the fats in the blood. There are 
several ways of analyzing the lipids. The most up to date is to 
separate them by density. So we speak of High Density Lipoproteins 
(HDL) and Low Density Lipoprote ins(LDL) and Very Low Density 
Lipoproteins. (VLDL). 
       Ideally, all adults may wish to have a plasma lipid 
measurement. As a second best, screening is recommended for high risk 
individuals. If your doctor thinks you are of this group you will 
automatically be told to have the study. If you would like to have the 
study done routinely,  please ask for it. Though Medicare has not been 
strict in the past this is not an insured benefit under the act. 
(Medicare was set up to pay for disease, not prevention).
       If a person in middle age has a high LDL and a high 
Triglyceride (TG) level, it is recommended he/she be treated. The aim 
is to bring the cholesterol towards a level of 200mg%. Calculations 
have been made of the ratio of HDL-c/TC-HDL-c. Though statistically 
valid these tend to be rather confusing to laymen.
       The mainstay of treatment is to reduce the intake of saturated 
fats and aim at an ideal body weight, things which are advisable in 
any case.
       The doctor's shopping list of medication is not very 
promising.
       1) The Fibric Acid drugs include Clofibrate, which is the 
only one proven to be effective in reducing the non fatal 
complications of high cholesterol, but it has too many side effects. 
Gemfibrozil (Lopid) is the newest of the group, but relatively 
untried.
       2) Nicotinic acid is undoubtedly effective, but the flushing 
and headaches make it intolerable to most patients.
       3) Exchange resins all cause sever gastro-intestinal side 
effects.
       4) Fish oil is effective in reducing the rare type 5 
hyperlipoproteinemia, but its safety is unknown.
       5) Lovastatin (Mevacor), which is the most recent addition, 
undoubtedly reduces LDL-c, but has not yet been shown to improve 
health in prolonged studies. Side effects recognized so far include 
liver damage, particularly in individuals who drink alcohol. It is too 
early to judge this agent's long term usefulness.
       In conclusion, most of us have more important risk factors to 
worry about and doctoring with drugs has a small, though definite, 
place in helping some patients with high blood fats of certain kinds.
       A more detailed handout, with even more scientific terminology
and a number of references is available.

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