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Ask Our Doctors – Dr. Waseem Hussain – Cholesterol Education – Appointments at 301-324-4968

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My name is
Dr. Waseem Hussain. I am a board-certified
family medicine doctor who works here
at Metropolitan Medical Specialist, an affiliate
of Doctors Community Hospital. Cholesterol is a very
waxy molecule. It's in the fat family
and the human body needs cholesterol, it makes about 70%
to 80% of the cholesterol in a person's body is made
by their body, it's made by the liver. The cholesterol is a big part
of neurologic tissue, it's a big part of the brain,
it's a big part of the membranes that make cells up.

The problem occurs
when there's too much cholesterol in the body. The old model,
let me go over that for a second,
was this basic idea that the total cholesterol
should be less than 200 and then depending
on the amount of risk factors that you have,
if you have not a lot of risk factors, basically,
let's say, you're 20 years old, you're in great shape,
you don't really have any medical problems at all
and you have a cholesterol that's 220. So, in that model,
you would look at that and you would basically say,
"This is a young person who doesn't have any
risk factors and their number should be less
than a certain number." Specifically, a low-density
lipoprotein or bad cholesterol number under like 160,
and so on, and so on. So, the more risk factor
somebody has, the threshold gets lower
and lower. On the other end
of the spectrum is somebody who has a lot of issues;
they smoke, they have diabetes, they have high blood pressure,
they're overweight, they've already had a heart attack,
they may have had a stroke.

In folks like that,
the recommendation was basically to get
the bad cholesterol under 70. But what happened is like–
what they found is the science behind a lot of that stuff
wasn't really backed up by a lot of sophisticated studies
because those numbers didn't take into account
all the different risk factors a person has. So, the new model
is basically based on assessing somebody's risk. Instead of looking at
somebody as this number is too high or this number
is too low, what we're really looking at
is this person a high-risk person for a heart problem or a stroke,
is this person a low-risk problem for a heart problem or stroke. Then there's a way
that we actually calculate that. What happens is–
step one in figuring this out is iyou get your cholesterol checked
and then what you would do is you take the breakdown
of the cholesterol and you go over it with your doctor.

What your doctor will do then
is he'll plug in all the different numbers
in your cholesterol profile into an equation
that takes into account how much good cholesterol you have,
how much total cholesterol you have, what are your risk factors,
have you had a stroke, do you have high blood pressure,
do you have diabetes? Those type of factors.
Your ethnicity is a factor. In this, a lot of
the old studies were just based on White people,
so the newer studies cover a larger swad
of the American population. So, it's a more accurate way
to assess somebody if they basically need medicine
or they don't need medicine or if they have a problem
or don't have a problem. A lot of it is genetic.

Like I said, 70% of the cholesterol
in a person's body is made by that person. So, even if you literally
just ate grass day in and day out, you would still,
if you have a genetic proclivity towards having
a really high cholesterol, have high cholesterol. So, genetics play a big factor,
but I think probably in our society,
a humongous factor really is how people eat.

Diets that are very high in carbs
make the cholesterol higher. You don't normally associate
carbohydrates with cholesterol, but what happens is if you eat
a lot of carbohydrates, and when I say carbohydrates,
I mean like white stuff, that stuff like rice,
white rice, white bread, white pasta, white potatoes. White potatoes are probably
the most toxic of all the carbs in the white things, so,
even if you're steaming your potatoes or boiling
your potatoes and baking them, it's creating a lot of inflammation
in your body because of the heavy carbohydrate intake
and then there's a chain reaction from that that actually causes
high cholesterol. So, that's one element;
heavy carbohydrate intake. The second element
is just a diet that's just too heavy in saturated fat. So, this stuff like
way too much butter, way too much red meat,
way too much fried food, a diet that's heavy in cheese,
shellfish has a lot of cholesterol in it.

When I say shellfish,
I mean shrimp, crabs, lobsters, even if they're not fried,
they have a tremendous amount of cholesterol in them. To some degree, eggs have
a lot of cholesterol. Though, our thinking
about eggs has been changing. A healthy person can still eat
a good amount of eggs and it's not going to screw up
your cholesterol that much. The dietary factors are critical. The carbohydrate intake elements
are essential, and then there really is an element of exercise
associated with this as well. So, again, if you're just sitting
most of the day and you're not that
physically active, that slows your metabolism down
and it creates a dysfunctional metabolism that feeds the system
that cause it to have a higher cholesterol. So, this, too, falls
into the category, I would say, of the silent killer type of thing. Most people have no clue
they have high cholesterol because there's no physical
manifestations of that. Very, very, rarely in certain
cholesterol syndromes where the cholesterol
is extremely high, you'll see subtle signs
on a physical exam.

You'll see people
have these weird, like white pimples scattered,
they're these yellow fatty pimples all over the body,
but outside of that, which I rarely see in anybody
because nobody– most people don't have cholesterols
that are that out of control, it's completely sound
and you can't tell. You can't tell until basically,
it's too late until after you've had a heart attack
or you've had a stroke or those type of problems. So, the only way
to really detect it is to get regular surveillance,
seeing your doctor, getting a blood test done,
that's basically the key to making that happen. It's a really common problem, about one out of three Americans
have high cholesterol and only about half
of those folks even know they have it
and of those folks who have it and who know who have it,
only a third of those folks are actually on medicine
and have it treated to the right level.
So, a lot of the cholesterol in our country
totally not even identified and not even treated
the majority of the time.

There is a distribution
in terms of who you see higher cholesterol in.
In terms of ethnic groups, across the board,
it's pretty much one out of three people
have high cholesterol. But Mexican-American men
have probably the highest rate of high cholesterol in guys
and African-American women have the highest rate in women
across the country. Definitely, if I have a new patient
and they are Mexican-American and they're a guy
or they're African-American and a female,
my radar is going to be up for basically looking
for high cholesterol issues in that population.

We always want to start off
with lifestyle changes. So, that goes back
to what we talked a little about before about
decreasing carbohydrate intake and basically sticking
to the principles of that Mediterranean diet
that we talked about which is whole grains,
lots of berries, really healthy nuts like walnuts, pecans,
and pistachios, using olive oil in your cooking,
salmon or herring or tuna two times a week. That's going to basically
be the foundation of it.

There are certain foods
that are known to actually lower cholesterol.
One family of foods that really helps
is actually apples. So, that old saying
about the apple a day keeps the doctor away,
that's completely applicable to this situation and there really is
good evidence that apples would lower cholesterol
if you eat one a day. Strawberries
are in that group as well.

Grapes are in that group
as well, and then there's actually a lot
of evidence that citrus, if you eat a lot of oranges,
that can actually lower the cholesterol as well.
There are some other subtle things; pomegranates can help.
Drinking green tea, there is some value to that
as well that can actually lower the cholesterol as well.
There is a lot of value to eggplants and okra.
If you eat a lot of eggplant and okra, that will also
naturally bring the cholesterol down. All of those things
have a common denominator. They have this stuff called–
many of them have these things called–
there's a natural occurring chemical in these healthy
fruits and vegetables called plant sterols
and that's basically how the cholesterol comes down.
Some people buy supplements.

If you go over the counter
and you buy a supplement, a supplement that can certainly
help bring the cholesterol number down is this thing
called red yeast rice. That is basically
a concentrated version of this stuff that's found
in a lot of the vegetables and that's over the counter
and relatively easy to take. So, that's the diet
and supplement part of the conversation.
Like I said, reducing carbohydrate intake
will have an indirect effect on the cholesterol and really help
the profile tremendously.

You want to treat
the other problems that often run with cholesterol
because most people who have high cholesterol,
they don't just have high cholesterol,
they also high blood pressure, they also have diabetes.
So, you need to address those two other issues
to health as well. No doubt about it,
weight's a major factor in the story as well.
In all of these things we’ve been talking about;
high carb diets, sedentary lifestyle,
poor sleep quality, that increases weight
and subsequently leads to a lot of bad eating behaviors,
the way your body metabolizes food gets messed up
and then that causes high cholesterol.
So, addressing that is part of treating
the high cholesterol issue.

Once we address
all of those issues, the other big,
big thing is medicine. There we have a class
of medications called statins. Statins are cholesterol
medications that have been around for almost 30 years now
and that's basically the gold standard in how
we are able to bring the cholesterol numbers down. Treating the cholesterol
and bringing the numbers down, that definitely helps dramatically. If you aggressively treat
somebody’s cholesterol through lifestyle modification
and through cholesterol medication– I also forgot to mention stuff
like fish oil and flaxseed. That's another great way
to bring the numbers down overall.
You can basically reduce somebody’s heart attack risk
by about 30 to 40% by doing those things. Cholesterol, when it’s moving through
the blood stream, it doesn’t just float there
by itself. Have you ever seen one
of those Ferrero Rocher chocolate things?
They’re like a shell of chocolate and then inside
is the good stuff and you eat that?
That's sort of what cholesterol– that's how it lives in the body,
it lives in this protein shell and that’s how it’s carried
from point A to point B in the body.

So, depending on what type
of protein shell is carrying the cholesterol,
that’s how we determine good cholesterol
and bad cholesterol. The protein shell,
the technical name for it, it's called lipoprotein.
LDL or bad cholesterol, that’s the type of cholesterol
that you don’t want to have too much of that lives inside
of this thing called low-density lipoprotein
and that’s what LDL is. HDL, which stands for
High-Density Lipoprotein, that lives inside this protein shell
of high-density lipoproteins. The more you have
of the high-density lipoproteins, the cleaner
your blood vessels are. So, in a perfect situation,
you want somebody who has a really high HDL,
that’s good cholesterol, and a really low bad cholesterol,
that’s LDL. Another factor that’s not directly
connected to cholesterol, but is an indicator of the overall
weight of the metabolized fat in their body is something
called triglycerides. Triglycerides
are a different molecule, but it’s more of a reflection
of exactly how much fat is in your body and how well
you metabolize things.

So, if you eat a lot of cheese,
you eat a lot of fried food, and you eat a lot of red meat,
you’re not only going to have a screwed up
bad cholesterol, but you have a lot
of the stuff called triglycerides. In a lot of folks, the higher
the triglycerides get, the lower the good cholesterol get
and that magnifies the cardiovascular risk
of having a heart attack or a stroke.
So, that’s what HDL and LDL is–
it’s an important distinction because a lot of times,
people will come in and they'll say,
“My cholesterol is over 200.” But when you look
at their profile, they will have a high
total cholesterol but a lot of their total cholesterol
is good cholesterol, so that’s good.
So, that’s why the breakdown of the different lipoproteins
is that’s going to be the way to really evaluate somebody’s
overall cardiac risk.

With these lipoproteins,
when we’re giving somebody medicine for it,
we know we’re giving them the right medicine
and we’re getting the result when we’re able to drop
their previous cholesterol level you were asking about
numbers before. If we can just get
their numbers down from where they were,
down to 30%, 40%, 50% lower than where they were,
that’s the goal. It’s not so much looking
for what number we’re trying to get to,
we’re trying to get a certain percentage
of that number down because that’s what been shown
to basically decrease the heart attack and stroke risk. For the natural
bad cholesterol level, it's usually 50 to 60
or usually less than that in many people. It’s a chain reaction
of bad things that happen. So, basically, what happens is
if you have too much cholesterol in your blood,
it basically screws up the plumbing. The walls of the arteries,
they start to develop the stuff called plaque.

Plaque is basically gunk
and junk that is rusting up and turning into a bigger
and bigger amount on the inside of the blood vessels. As that gets bigger and bigger,
then it starts to obstruct the natural flow of blood
and if it gets obstructed enough, you basically end up with a stroke
or a heart attack or a kidney failure. Those are basically
the biggest problems that occur with it. What happens is that
when that plaque gets built up like that,
eventually, the top of the plaque gets torn off
and then blood clots to the top of that,
and that’s how you get a blood clot
and you block things off and you have a heart attack
or a stroke.

So, the cholesterol,
if you can control the amount of cholesterol
in the blood, then you don’t get
the plaque buildup. That’s the whole point
of basically treating cholesterol to avoid that from happening. Having some of these
other diseases actually, stimulate the production
of higher bad cholesterol. One of the biggest problems
is chronic kidney disease. As the kidneys
are getting beat up by age, beat up by high blood pressure,
beat up by taking too much Advil, Motrin,
ibuprofen, and alcohol.

As the kidney function
decreases with age, and especially if that’s accelerated,
then the cholesterol starts to go up as the kidney function
starts to go down. So, when we’re having
conversations about cholesterol, it’s important to look
all the organs, not just the heart and not just the cholesterol,
but getting the kidneys checked out as well.
Another big organ that’s a factor in cholesterol
metabolism is your thyroid. Low thyroid
is a very common problem and if the thyroid gets too low,
that starts screwing up the cholesterol profile as well
and you start to see rises and bad cholesterol
and decreases in good cholesterol if the thyroid is not
well controlled. So, kidney disease
and thyroid disease, but the biggest one of all
is going to be diabetes. Diabetes basically creates
this really screwed up metabolism in the body
so the body cannot handle the cholesterol as well. Diabetes is very strongly
associated with messed up cholesterols. We want to be on the lookout
for that as well when we catch somebody
with high cholesterol. We want to also ask the question;
how is your blood sugar, how is your thyroid,
how is your kidney functioning? There are ways
that we can tell how aggressive we need to be about managing
somebody’s cholesterol and the way we can tell
besides using these risk factor equations
that I was talking about before is there are some
other tests that can be done on a blood test.
One blood test that you may want to ask
your doctor to check is something called high-sensitivity
C-reactive protein test.

Your doctor would know about this.
Basically, when we’re making decisions about it
if we're going to put somebody on cholesterol medicine or not,
that’s a valuable variable to look at.
This number called CRP or cardiac CRP,
it basically tells us indirectly how much inflammation
and stickiness is in your blood vessels.
If you have a really high number on this,
then that means you’re at a higher risk for heart disease
and you should be more aggressive with managing
your cholesterol and maybe not just treat you
with diet and exercise. There's another great modality
that we started to use to help stratified people
into who should be treated and who should not be treated,
it’s called coronary calcium scoring and a lot of the places
around here offer that. It’s basically a low-expense way
to basically– actually, you get a look at the heart.
Basically, it's a CAT scan that looks at calcium build up
in the blood vessels of the heart.

Remember when we were talking
about plaque? The plaque, the stuff
that blocks up the blood vessels? Well, a big part of that blockage–
the big part of the stuff that blocks the blood vessels,
that plaque is not just cholesterol, but it’s actually calcium deposits.
So, you can detect those calcium deposits
on a CAT scan and if you have a lot of that,
well, that may change the way your doctor looks at you
and you would be somebody that we would want to be more
aggressive about treating with cholesterol.
Those are some of the other ways that we make a decision
about who should be on medicines,
who should not be on medicines, can we manage this
with just lifestyle alone? The hospital has a variety
of different health fairs, and then we’ve alluded to the van.
The van also does helps screenings.
At these screenings, very frequently,
they'll do these right on the spot blood test
that tells you at least what your total cholesterol is.
Some of the testing can actually show you
the breakdown of good cholesterol
and bad cholesterol.

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