The HDL/triglycerides trap.

The HDL/Triglycerides Trap

If your cholesterol is below 200, most doctors--and the government--say you needn't worry about getting a heart attack. Wrong, says William Castelli, director of the Framingham Heart Study. If you have a low HDL ("good") cholesterol level, you may still be at risk.

"There's a subgroup of people who have an HDL under 40 and triglycerides over 150," he explains. "These people have galloping proression of their cholesterol deposits, which will eventually lead to heart disease, and the average physician is not picking it up."

It's also wrong for physicians to assume that women and older people needn't worry about their colestrol, says Castille. He corrects these and other common miscomceptions in an interview staring on page 5.

Q: The National Cholesterol Education Programs says that your risk of heart disease isn't high if your cholesterol is less than 200. Is that wrong?

A: It could be. Twenty percent of heart attacks occur in people with cholesterols under 200. You'll miss them if you only measure total cholestrol. you can't interpret a total cholesterol between 150 and 200 unless you also measure HDL.

Q: How high should your HDL ["good"] cholesterol be"

A: Your total cholesterol divided by your HDL should be under 4.5. The ideal ratio is u nder 3.5. At ratio between 3.5 and 4.5, your altherosclerosis is slowly progressing. If you live long enough, you'll make lesions in your arteries.

Q: Why is HDL so important?

A: Your cells need cholesterol to make cell membranes and hormones. But when your total cholesterol is over 150--or your LDL ["bad"] cholesterol is over 90--the cells have more cholesterol than they can use and no way to get rid of the excess. They can't break down or oxidize it, so it starts to pile up as a waxy deposit that will eventually choke the cells.

The only way to get rid of the excess cholesterol is to get HDL to pick it up and bring it to the liver, where 95 percent of it goes out of the body. As John Oram, of the University of Washington is Seattle, says: without enough HDL you could turn into a candle.

Q: Isn't a high LDL the best predictor of heart disease risk?

A:LDL is a much better predictor than total cholesterol. But with a total between 200 and 240, the total/HDL ratio predicts your risk of heart disease 3-4 times better than LDL and 5-6 times better than total cholesterol.

If your total is over 240, LDL is a better predictor, because few people have enough HDL to bail them out of a higher LDL.

Howver, you will find the rare person who has a total cholesterol of 300 and a high HDL, say 100. Instead of starting him on a diet, the doctor puts him on the drug lovastatin. But this guy will go to his doctor's funeral, and needed only a diet.

Q: Aren't people with the highest cholesterols at greatest risk?

A: When I went to Framingham in 1965, it was taught that you only treat people with cholesterol over 300. Unfortunately, if you only treat those people, you miss 75 percent of the heart attacks. The cholesterol of the average man who gets a heart attack is 225. Most heart attacks occur between 200 and 240.

Now, Elizabeth Whelan [of the industry-funded American Council on Science and Health] says the National Cholesterol Education Program calls a cholesterol between 200 and 240 "borderline" as if they're not sure if it's bad. Then she asks whether we should bother people for something we're not sure about.

You know, Whelan claims she's an epidemiologist, but the first rule of epidemiology is that you've got to go where the epidemic is. If you go to Peoria and the epidemic is in Hackensack, you'll miss the epidemic, elizabeth. Well, the epidemic is between 200 and 240.

Q:Should people worry about their triglycerides?

A: There's a big debate about triglycerides. In women, it's a better predictor of heart disease risk than LDL, unless their total cholesterol is over 350 and their LDL is sky-high.

In both men and women, we think there's a subgroup with high triglycerides--150 or higher--who also have very low HLD--under 40. [Triglycerides are transported in the blood primarily in very low density lipoproteins--VLDLs.]

These people apparently have a different kind of VLDL, which turns into a kind of LDL that is even worse for their arteries than ordinary LDL. We need to find these people.

Q: Arent doctors told to worry about triglycerides only if they're over 250?

A: Yes. That's part of the problem. We want doctors to consider triglycerides high if they're over 150, because the bulk of the people who have this bad VLDL have triglycerides between 190 and 210, to go along with HDLs under 40.

Q: Are those the only clues to finding these people?

A: No. We think that this syndrome starts in men and women in their middle age when they put on a spare tire and get an increased waist-to-hip ratio.

They also have the highest blood sugar you can have without having diabetes--between 95 and 110--so the average physician will miss it. That's because they have insulin resistance. It's as if their insulin doesn't work as well, so blood sugar backs up in their blood. And they go on to develop deabetes at twice the rate of other men and women.

These people also develop high blood pressure and an elevated uric acid, but not more than 6 to 8 in men or 4 to 6 in women. So it's not the high uric acid that doctors treat.

Q: What about people who only have some of these risk factors?

A: If they just have the low HDL and high triglycerides, they'll still run a higher risk, but not as high. This whole syndrome is being missed in American medicine.

Q: What treatment do you recommend for these people?

A: The first step is to go on a diet and lose the spare tire. I'd give them a good six months to seriously try a good diet, even engaging a dietitian.

If they fail to bring their triglycerides under 150 and their total/HDL ratio under 4.5, I'd go to drugs. That is, unless their total cholesterol goes below 150 or their LDL cholesterol goes below 90. Then I would leave them alone.

Q: What about exercise?

A: Exercise works beautifully--it tends to raise HDL and lower LDL. And the more you exercise, the more you can eat. It makes life more interesting.

Q: Which drugs do you recommend?

A: The fibrate drugs like gemfibrozil. Not niacin, because it raises their blood sugar and uric acid even higher. Lovastatin doesn't control triglycerides and HDL as well, and the resins [like cholestyramine] frequently make them worse.

Sometimes we put people on gemfibrozil and if their LDL comes back up, we can add resins and even niacin. Studies in helsinki and Stockholm have shown that if you treat people who have low HDL and high triglycerides with drugs, you can cut their heart attack rate in half in five years.

Q: What else are doctors missing when they treat heart disease?

A: It's idiotic to say that we shouldn't measure cholesterol in the elderly. their total cholesterol isn't as good at predicting the risk of heart disease, but their total/HDL ratio is.

Let's face it. Most of us have this gut feeling that if you came through this hail of hot dogs and hamburgers that rain down on us and made it to 70 without getting a heart attack, you had some protective factor and we should leave you alone forever.

But the data show that a 70-year-old is twice as likely as a 50-year-old to have a heart attack over the next two years. This does not suggest that the old tolerate. cholesterol better. Perhaps they tolerate it worse.

Q: Do women need to worry about their cholesterol?

A: Yes. After menopause, the total,LDL, and HDL cholesterol, the total/HDL ratio, and triglycerides predict better in women than in men who's going to get a heart attack. At least a half dozen intervention triils show that cholesterol and heart attack rates fall as readily in women as in men who are put on cholesterol-lowering diets or drugs.

Q: Is there any difference between a man's and woman's risk?

A: Yes. In essencE, women don't get the disease before menopause, but after menopause, it only takes them six to ten years to catch up to ment. That's because they have smaller arteries.

The heart disease rates are the same for 60-year-old women as for 50-year-old men, and the same for 70-year-old women as for 65-year-old-men. Women and men aged 75 to 80 have identical rates, but by then there aren't many men left.

There are plenty of reasons for younger women to watch what they eat. Studies from China show that if your cholesterol is low, you won't get breast or colon cancer or diabetes either.

Q: Are there any Americans who don't have to worry about heart disease?

A: Hardly anyone. within the last three or four years, with the help of ultrasound, we can look in inside the carotid artery in the neck. We find that 70 percent of the men and women over 65 in Framingham have lesions big enough to see easily, and that ten percent have at least a 50-percent blockage. Once it's in your carotids, its already in your coronary arteries.

Q: Then why dont 70 percent of men and women appear sick?

A: Nothing happens until you get 50-percent blockage of an artery in your heart. The first symptom is angina, a tightness, heaviness, or pain in the chest that usually occurs with physical exertion and is relieved within minutes if you rest. Occassionally it will radiate into your neck, left shoulder, or arms.

When you add a clot to the blockage, you have a heart attack. Now, I can dissolve the clot with drugs like TPA, but we're back to the blockage that was there just minutes before the clot.

About one-third of the women and men in America will have a clinical episode, such as a heart attack, stroke, or a blockage in an ertery in the leg, before they're 65. The rate of these diseases is higher after 65, and not quite half of us in America will die from this process.

Q: Is there any group of people who are free of heart disease?

A: Yes, but they live in Asia, Latin America, and Africa. Now, I can give those people the disease, too. All I have to do is fly them to Rio, tokyo, or Taipei with a generous food allowance.

Q: How can we take the bad stuff out of the Amercian Diet?

A: We should get no mre than ten percent of our calories from saturated fat. At 2,000 calories a day, that's only 22 grams of saturated fat. The average American eats about 40 grams a day.

Let's take a hamburger patty. Choice beef, which is what's usually in the store, has 12 to 15 grams of saturated fat. You blew more than half of your ratio for the day on a single hamburger.

But now you can buy Select beef that's not fattened in a feed lot. It's not the Select beef that's sold most supermarkets. I get my ground beef mail-order from Dakota Lean in Winner, South Dakota. It's only ten percent fat. That's less than five grams of saturated fat in a hamburger.

Q: What do you tell people who are tired of chicken?

A: There are many more choices. You can eat beans. You can eat 97% fat-free-ham--lean ham, not pork chops. It has the same amount of saturated fat andcholesteral as chicken.

Q:What about shellfish?

A: There are two kinds. Oysters, clams, scallops, and mussels don't move. They lay around and suck in the phytoplankton--the vegetables of the sea--which makes these shellfish the vegetarians of the sea. Just like vegetarians all over thw world, they have the lowest cholesterol. I say if you can't be a vegetarian, eat one from the sea.

The shellfish that do move--lobster, crab, shrimp--are not as low in cholesterol, but they're so low in saturated fat that you're no worse off eating them than the lowest-cholesterol, lowest-saturated-fat meats. And seafood has beneficial fish oils.

Q: Should non-meat-eaters worry about getting protein?

A: It's easier than you think. You can even get enough from whole-grain cereals like rice and oats. We do a funny thing in this country. We take wholegrain cereals and remove the protein-rich wheat germ and sell it in a bottle. we remove the bran and sell it in a box. what's left over we puff up, fluff out, flake, and spray with chocolate and strawberry flavors.

The newest cereals--Teenage Mutant Ninja Turtles and Batman--have one gram of protein per ounce. Oats have six grams of protein in an ounce.

Q: what's the least amount of exercise people have to do to protect their hearts?

A: The biggest benefit from exercise comes in the first 2,000 calories per week. Doing a lot more is not going to change your risk appreciably.

Now, 500 calories is what you'd use up if you were the supreme couch potato. So how do you get those other 1,500? If you jog a mile, you use up a little over 100 calories. If you walk briskly for a mile, it's still 100. I suppose you could even crawl a mile.

So we're talking about two miles a day; 15 minutes out and 15 minutes back. That's 200 calories a day for seven days, for a total of 1,400 calories. Most people should be able to do that much.

Q: How many heart attacks can we wipe out by changes in lifestyle?

A: All of them. There are five billion people on this earth. four-billion-plus will never get a heart attack. Why can't we be like them?