• Blacks Who Take Vitamin D May See Dip in Blood Pressure – health.com
• Physician Gender Unrelated to Patient Mortality – medscape.com
• Job Burnout Independently Linked to Coronary Heart Disease – medicalnewstoday.com
• Eating Less: Olive Oil Makes You Feel Full – sciencedaily.com
• Long-Term Outcomes in Elderly Survivors of In-Hospital Cardiac Arrest – nejm.org
• High-Fat Dairy May Increase Risk of Death From Breast Cancer Relapse – foxnews.com
• MS Patients Did Not Benefit From CCSVI Intervention – eurekalert.com

Last week, in part 4 of this blog series we spoke about the statins. This week we will look at other cholesterol medications. Another very effective method for decreasing LDL is by combining a statin with other drugs.

Medications

• One of the most effective add-on medications is Ezetimibe. This medicine works by blocking cholesterol absorption in our small intestine. It’s not just the cholesterol we eat that is blocked; more importantly it’s the enormous amount of cholesterol that is recycled daily between our liver and intestine. At this point, clinical trials have failed to demonstrate a reduction in heart attack and stroke by using Ezetimibe. Still, many lipid specialists (me included) believe that future trials will demonstrate its importance in particular patient populations.
• Another important class of cholesterol-lowering drug is called the bile acid sequestrants. Welchol is the most commonly utilized of these medications. By blocking the reabsorption of bile acids in our intestine our liver is forced to produce more bile acids from their precursor, cholesterol. Interestingly, WelChol also has the added benefit of lowering blood sugar and increasing HDL. Patients with very high triglycerides should be careful of this medication because it can increase triglycerides further. Like Ezetimibe, WelChol is best used in combination with a statin.
• Niacin, vitamin B3, is also often used in cholesterol management. It’s best known for its impact on raising HDL and lowering triglycerides. Niacin also has an effect on LDL however. It increases LDL particle size, and by so doing, can actually decrease LDL particle number. Niaspan is the pharmaceutical version of niacin that is most commonly utilized by the physicians. It’s method of action is poorly understood and quite complex. Like WelChol and Ezetimibe, niacin is also best used in conjunction with a statin.
• Fenofibrates represent yet another class of medications that is used for cholesterol management. Their dominant effect is to lower triglycerides and raising HDL. At this point clinical trials have not found them to be effective in decreasing cardiovascular events, but they are improving lipids and lipoproteins.
• The active ingredients in fish oil, DHA and EPA, can also have an effect on lipids and lipoproteins. They can lower triglycerides, increase HDL, and sometimes increase particle size and by so doing decrease particle number. In patients with very high triglycerides, fish oils can at times increase LDL cholesterol. Their method of action is also quite complex and beyond the scope of this blog.

Diet and Exercise

In managing cholesterol abnormalities we should never neglect the value of diet and exercise.  A healthful diet will unquestionably improve your lipid and lipoprotein profile. Even when taking a statin, a healthful diet must be maintained.  In fact, there is a specific dietary program called the Portfolio Diet that is geared specifically to lower cholesterol. Exercise can also benefit your lipid and lipoprotein profile. Daily exercise for 30-60 min. can significantly decrease your LDL particle number, increase your HDL, and lower your triglycerides. The bottom line, if you’re physically capable, exercise every day.

A few other cholesterol management strategies are either in the pipeline, or utilized only in very high risk patients. They will be the subject of next week’s blog, part 6 in this series, Cholesterol and Vascular Disease.

Heart disease remains the leading cause of death for men and women. In the fight against heart disease our approach must be to emphasize prevention with a focus on achieving and sustaining desirable behaviors.

1)  Don’t smoke. If you smoke, find a way to quit. If you don’t smoke, don’t start. Smoking is toxic to the body. Every organ system is affected, but certainly it is a BIG risk factor for heart disease.
2)  Eat a healthful, balanced, varied diet to help prevent heart disease, hypertension, and type 2 diabetes. Eat a variety of fruits and copious amounts of vegetables; eat whole grains and complex carbohydrates like oatmeal. Choose lean proteins. Include healthful fats found in salmon, avocados and nuts, and limit saturated fats found in fatty meats and cheese. Avoid processed food, fried food, fad diets and extremes. Limit salt and simple sugars; sugar is our enemy. Drink more water and less soda.
3)  Maintain an Ideal Body Weight. You can enjoy a healthful diet and still be overweight. Exercise portion control and enjoy smaller more frequent meals. A good measure of where you stand is the BMI; optimal is less than 25, overweight is 25-30, obese is greater than 30. Cardiovascular risk increases with elevated BMI. Visit www.bmi-calculator.net to calculate your BMI.
4)  Reduce stress. Try exercise – guaranteed to relieve stress. Walk, dance, garden; take a friend and chat, take a dog and run. The possibilities are endless. Listen to music. Take a series of deep breaths in through your nose and out through your mouth. Turn off your phone and disconnect. Get more sleep.
5) Exercise. This is not optional. Exercise improves heart and lung function, decreases resting blood pressure, decreases body fat, decreases total and LDL “bad” cholesterol, raises HDL “good” cholesterol, increases energy levels, increases tolerance to stress and depression, and controls or prevents the development of diabetes.  Include aerobics (walking, biking, elliptical), resistance  (strength training), and stretching. With time, your body will respond by increasing muscle mass and tone and decreasing body fat.  You will be thinner, stronger, more limber and flexible, and your body will function better and be less vulnerable to orthopedic injury. You will be healthier and decrease your risk of cancer, heart disease and chronic illness.

See your doctor regularly to ensure optimal control of several key factors:

6)  Healthful lipids including cholesterol, triglycerides and lipoproteins,
7)  Healthful blood pressure,
8)  Healthful blood sugar,
9)  Optimal vitamin D level; 25-hydroxyvitamin D should measure 40-50 ng/dl.

10)  Take appropriate nutritional supplements: A good daily multivitamin with just 100% of essential vitamins and minerals is a great foundation.  Research shows 80 to 90% of the population does not achieve the recommended daily value (RDV) for each vitamin and mineral each day, nor do they even come close.  And, bear in mind that the RDV levels for each nutrient are only intended to guard against severe nutrient deficiency diseases, but are not intended to serve as levels of vitamin and mineral intake that are optimal in regard to maximizing our well-being and longevity.  Supplement calcium according to your individual needs and vitamin D when needed. Take a high quality fish oil with 1000 mg combined DHA+EPA to boost your omega-3 intake. Beyond the protective effects demonstrated for heart disease and cancers, scientific evidence strongly indicates that the omega-3 fatty acids, DHA + EPA, may have potential benefits in the prevention and/or treatment of myriad health conditions.

Did You Know…?
The American Heart Association (AHA) 2020 Impact Goal is to improve the cardiovascular health of Americans by 20% while also reducing cardiovascular deaths by 20%. In order to achieve these goals, the AHA adopted a new concept of cardiovascular health, one that is made up of seven components. These components include four ideal health behaviors–not smoking, body-mass index (BMI) <25 kg/m2, physical activity at goal levels, and diet that includes three or more servings of fruits and vegetables daily–and three ideal health factors, including total cholesterol <200 mg/dL, systolic blood pressure <120 mm Hg and diastolic blood pressure <80 mm Hg, and fasting plasma glucose levels <100 mg/dL.

Study: Cardiovascular Health Linked With Reduced Mortality

Individuals meeting five of seven cardiovascular health measures selected by the American Heart Association (AHA) had a significantly lower risk of all-cause mortality and deaths from diseases of the circulatory system compared with those who met none of the metrics.
Ford ES, Greenlund KJ, Hong Y. Ideal cardiovascular health and mortality from all causes and diseases of the circulatory system among adults in the United States. Circulation 2012.

Americans are eating too much salt. A recent study published by the Center for Disease Control found that the many Americans consume way too much salt. The study, based on surveys of more than 7,200 people in 2007 and 2008 (including nearly 3,000 children), found that approximately nine out of 10 persons in the United States ingest more sodium than recommended. Daily dietary sodium intake, excluding sodium added at the dinner table, averages 3,266 mg/day. The Dietary Guidelines for Americans recommends a daily sodium intake 2,300 mg overall and 1,500 mg for specific at-risk populations comprising about half of the population. Those numbers indicate that many Americans may be consuming up to twice their daily-recommended intake of sodium per day.

Health problems related to high sodium consumption include high blood pressure, or hypertension, which in 2008 was reported as a primary or contributing factor in approximately 348,000 deaths in the U.S. Hypertension is widespread, with thirty-one percent of adults in the United States being afflicted and fewer than half of those having their blood pressure under control. A mere 33% reduction in the average American’s daily sodium intake would potentially avert up to 81,000 deaths, and save an estimated $20 billion health-care dollars annually.

Sources of Dietary Sodium
Contrary to popular opinion, the problem with salt over-consumption lies not in the use of a salt shaker, but in eating the wrong foods. Americans get approximately two-thirds of their dietary sodium from processed foods and drinks purchased at their local supermarket or convenience store, and about one fourth from restaurant food — a source that has the highest per-calorie dietary sodium level.

Results of the CDC’s study indicate that a whopping 44% of sodium intake comes from 10 common foods (highest to lowest):

• Bread and rolls
• Cold cuts/cured meats
• Pizza
• Poultry
• Soups
• Sandwiches such as cheeseburgers
• Cheese
• Pasta mixed dishes
• Meat mixed dishes
• Savory snacks like chips and pretzels

What Can Be Done?
People must be more careful about their food choices. And food manufacturers need to make reducing the sodium content in their food products a top priority. Consumers need to become more proactive – demand that manufacturers and restaurants strive to reduce excess sodium added to foods. States and localities can implement policies to reduce sodium in foods served in institutional settings like schools, child-care centers, and government cafeterias.

Six simple tips:

• NEVER use a salt shaker (it goes without saying, but I had to say it anyway).
• Cooking fresh food at home is the best way to reduce sodium intake. It is also the best way to stay lean.
• Do the math — monitor your daily sodium intake and try to keep that number under 2,300 mg.
• Avoid high salt content processed foods and those on the list above — a typical frozen 5 oz. turkey dinner can contain over 700 mg of salt!
• Read those supermarket food labels — choose low sodium alternatives. Watch out for misleading food labels that claim “low sodium’ but really mean slightly “less” sodium.
• Avoid salty items at restaurants. For instance, Red Lobster’s Admirals’ Feast packs a staggering 7,106 mg of sodium and a McDonald’s Chicken Club Sandwich contains roughly 1,690 mg of sodium. Ouch!

Additional information is available at www.cdc.gov/vitalsigns