Cholesterol One of the fun parts of hunting camp is sitting around the dinner table with a group of folks you just met and exchanging hunting stories. Most outfitters go out of their way to pile on the food especially after a long cold day in the deer stand. Predictably there aren’t many Vegans at the table that overflows with meat, cheese dishes and the like. After a couple of days inevitably somebody will comment on the food and ask us: “Really, how important is a cholesterol number?” Considering how often medical science seems to reverse itself about risk factors the answer is not self evident. We’re going to help cut through the swamp of numbers and initials so you can take action if needed. Literally billions have been spent in private and public monies trying to answer this cholesterol question. The complexity of human behavior and lifestyle makes a simple answer impossible. Just like smoking not everyone who has high cholesterol levels will have a heart attack nor will every person who smokes gets lung cancer. MD stands for medical doctor and not medical deity so both of us limit our crystal ball prediction act as much as possible. That having been said some basic facts are not in dispute and are very important to getting the right answer for you. Cholesterol comes in many forms in our bodies. In a sense you can use the analogy of weight. Somebody who weighs 250lbs may be in awesome shape or appear to have their own zip code. It depends on the composition of the weight; is it muscle or fat as the dominate tissue. Similarly with cholesterol there are “good” and “bad” types so a total number has limited usefulness. So knowing the total while important isn’t really enough information. It is also important to know that cholesterol does not exist in a vacuum; it interacts with your system in a unique manner. There are factors that amplify the risk of elevated “bad” cholesterol. These include the usual suspects: family history of early coronary artery disease, smoke, overweight, doesn’t exercise diabetes, high blood pressure, and being male. The more co-morbid risks the more important the cholesterol assessment. So called “good” cholesterol derives its reputation because it protects against coronary artery disease. Specifically this “good” cholesterol goes by the name of HDL short for High Density Lipoprotein. Generally speaking the higher the HDL the better in terms of reduced risk of a heart attack. Alas, it is more complicated than the picture just painted. You see there are various types of HDL and HDL 2b is the subtype that really does the protection work. So if your HDL is very high, say 70, but only 2% is HDL 2b you are at significant risk for coronary disease. It is crucial that you get your cholesterol totals fractionated if you (and your doctor) really want to do a risk assessment and hence a risk reduction plan. How does HDL 2b work in the body to reduce the risk of coronary disease? The HDL 2b protein actively soaks up free floating cholesterol from your blood. Once bound, the cholesterol is delivered back to your liver which disposes of it. So obviously the more HDL2b you have the better, no matter how high your total cholesterol. Your individual amount of HDL 2b is an inherited trait controlled by your genes not your diet. While you can increase this number, you can’t do so easily or that dramatically. The only ways to increase your HDL2b is heavy aerobic exercise or high doses of Niacin which is a B vitamin. Niacin at the doses required is a prescription and not without side effects so do not try this at home without medical supervision! A point about alcohol needs to be made here. Alcohol does in fact increase your HDL, just not HDL 2b. Further, while alcohol can be heart healthy, the benefit is very dose dependent. A single, solitary drink per day reduces the risk of coronary disease. But more than one or two drinks per day can dramatically increases the risk of alcoholism. Do not begin a course of “medical alcohol consumption” without a detailed discussion of risks and family history with your doctor! The “bad” cholesterol is known as LDL (low density lipoprotein). The higher this number is, the greater your risk. Ideally, you want this number under 100 to be considered low risk but as with HDL, it is not as simple as that. The complexity derives from the fact that there are many different sizes of LDL cholesterol. The smaller and denser the LDL particle the easier it can get push through the arterial wall and build a plaque. The larger or more buoyant the LDL particle the harder it is to get through the arterial wall so its ability to form plaques in your arteries is much reduced. Obviously, you want the all your LDL to be large, buoyant particles. How much of what size and density your LDL particle size is also genetically inherited and not related to your diet. Your diet can increase or decrease your total LDL amount but not the particle size. The only thing found to increase your particle size effectively is again large doses of niacin. Other non-dietary approaches involve reducing the total amount of LDL. There are several classes of effective medications that can reduce your total LDL regardless of particle size. The most commonly used class is the “Statins”. There are others as well and the choice of medications (if needed) is a decision between you and your doctor. We want to stress to you that knowing just you total cholesterol is not a sufficient amount of information to draw many useful conclusions. It is analogous to being told by your guide to bring a 30 caliber rifle. A 30-30, a .300 Ultra magnum and a 30-06 are all 30 caliber but with vastly different utility. We strongly suggest you not settle for incomplete information. Be pro-active with your doctor and insist that they draw a cholesterol panel that includes a break down of your HDL types and a delineation of your LDL particle sizes. That way you not only know what your total cholesterol, total HDL and total LDL levels are, you now have your HDL 2b levels and LDL particle size information. Now your risk can be much more accurately gauged and your treatment if needed can planned meaningfully. We don’t want to wade too deeply into the dietary issues around cholesterol as that can be even more complicated and awaits another day. Some basics are helpful however. Cholesterol comes from animal sources. Vegetable oils and fats do not contain cholesterol. The highest concentration of cholesterol is in egg yolks, second in line is the delicious fatty chicken skin we all love, then comes the not so lean red meats and it falls off from there. Any oil or fat derived from animals is generally speaking, high in cholesterol. So as usual, if it tastes good, spit it out because it is probably bad for you. As practicing physicians in the age of the internet we encounter better informed patients then when we started practice. Your health care is a partnership with your doctor. There is nothing disrespectful or breaching an unspoken protocol to insist on proper risk assessment. Treatment based on incomplete information can at best be incomplete. Since 50% of us will die from cardiac problems this is no small side show. We hope this clears up all the confusion on cholesterol and helps you make informed decisions with your doctor about your heart health. So as usual be safe and enjoy the outdoors.