High Cholesterol

High Cholesterol

It's a Numbers Game
for Women

Debbie was stunned. Standing in her office with the cholesterol report lying on her desk, she figured there had to be some mistake. The report showed she had a total cholesterol level of 255 mg/dl--about 45 points higher than the national norm and about 55 points higher than any doctor ever wanted to see it.

Yet Debbie, 42, followed a low-fat diet. She avoided liver and eggs. She ran four or five times a week.

How could her cholesterol be so high? And how dangerous was it?

Probably not half as dangerous as Debbie thought. Because, while studies indicate that high cholesterol predicts heart disease in men, what's high in men is not necessarily high in women.

"A lot of women are falsely worried about high total cholesterol levels," says epidemiologist Robert D. Langer, M.D., assistant professor of family and preventive medicine at the University of California, San Diego. "Largely based on data from middle-aged men, national cholesterol screening guidelines classify adults into three risk groups based on total cholesterol."

According to those guidelines, adults with a total cholesterol level of more than 240 mg/dl are said to have the most risk. And those with a total cholesterol of less than 200 mg/dl have the least. Those who fall somewhere in the middle have "borderline" risk.

Our Extra Bit of Protection

These evaluations of risk may be misleading for women, because total cholesterol is only part of the story. Total cholesterol is a combination of LDL cholesterol, the "bad" cholesterol that can clog arteries and set the stage for a heart attack, and HDL cholesterol, the "good" cholesterol that sucks up LDL and transports it to the liver for recycling. And although researchers are still trying to figure out why, women's HDL levels are usually at least 10 to 12 mg/dl higher than men's.

Debbie, for instance, found out that her HDL cholesterol was extremely high--93--and her LDL was low. So although her total cholesterol was high, her doctor told her that her risk for heart disease was almost nonexistent. The high HDL that women tend to have is added protection against heart disease. But it's also just enough to get them wrongly classified as "at risk" by the national guidelines if their doctors are only screening for total cholesterol.

In a study of 875 women, for example, Dr. Langer and his colleagues found that total cholesterol levels would have placed 31 percent of the women in a high-risk group if doctors used the national cholesterol screening guidelines. If doctors took HDL cholesterol into consideration as a second step in the screening process, fewer than 15 percent of the women were actually in the high-risk group.

In other words, more than half the women told by their doctors that they were seriously at risk for heart disease didn't need to worry about it--because their HDL was sufficiently high.

The same thing happened with the 47 percent of women in the study whose total cholesterol levels placed them in the "borderline" risk group. Once doctors looked at the HDL number, they found that fewer than 25 percent of the women were actually at borderline high risk.

As a result of ignoring the differences between men and women, researchers concluded, the national screening guidelines used by most doctors mistakenly identified at least three out of ten women as having cholesterol levels that put them at risk for heart disease.

How Much HDL Do We Need?

The value of HDL cholesterol cannot be underestimated. Some researchers say it actually "neutralizes" the effects of LDL cholesterol on the heart. And long-term studies of thousands of women here and abroad indicate that increasing HDL levels by 10 mg/dl can reduce the risk of heart disease anywhere from 42 to 50 percent.

How high should HDL be? Here again the standards are different for men and women because their average levels are different. In men, an HDL level of less than 35 is harmful. For women, an HDL level this low may be even more harmful, since "the average woman's HDL in the United States is between 55 and 60," says metabolic specialist Margo Denke, M.D., associate professor of internal medicine at the University of Texas Southwestern Medical Center in Dallas and a member of the National Institutes of Health panel of experts on HDL and heart disease. The panel sets the national standards for healthful cholesterol levels.

In a study at Johns Hopkins University in Baltimore, researchers found that women with HDL levels below 50 mg/dl were more than three times as likely to die of heart disease as women with higher levels. As a result, some researchers advocate that levels be kept as far over 50 as possible.

What You Can Do

The general rule is that you can reduce your risk of death from heart disease 5 percent for every point you increase HDL. How do you increase HDL? Here are the three strategies that have been proved to be effective.

Do not smoke. "The biggest cause of low HDL is cigarette smoking," says Dr. Denke. Studies indicate that HDL levels are 5 to 9 mg/dl lower in smokers than in their smoke-free friends.

Join a gym. Scientists have found that regular exercise can raise HDL 10 to 20 percent. Weight training with exercise machines increased women's HDL by 5 percent in one study, while walking or running a total of six miles every week boosted HDL 3 mg/dl in another. And in a third study, researchers found that it didn't really seem to matter what kind of exercise you do as long as you burn off 1,000 calories a week--the equivalent of walking about 30 to 45 minutes three times a week.

"Exercise will increase HDL levels in some more than others," says Dr. Denke. And every movement counts. "If you exercise a small amount, it's a small increase. If you exercise a great amount, it's a great increase."

Lose weight. "If you're more than 10 or 20 pounds overweight, your HDL can be depressed 8 to 10 mg/dl," says Dr. Denke. Studies have shown that, in any group of people, those who are fattest will have HDL levels that are 10 to 15 percent lower than those who are leanest.

Defending Your HDL

Since cholesterol is essentially the transportation system throughout the body for any fat you eat, a low-fat diet has been the prescription to remedy high cholesterol for over a decade. The only trouble is, a low-fat diet lowers HDL as well as LDL. In a study of nearly 2,000 women at the University of California at Los Angeles, researchers found that three weeks on a strict low-fat, high-fiber diet that derived 10 percent of its calories from fat did four things: reduced body weight by 4 percent, lowered total cholesterol by 21 percent, lowered LDL by 19 percent and lowered HDL by 19 percent.

So what's the best way to get a healthful, low-fat diet without losing the benefit of HDL?

When it comes to cholesterol control, says Dr. Denke, research shows the best diet for women has 30 percent of calories from fat. This diet lowers LDL without affecting HDL, according to Dr. Denke. When a woman's diet gets below 30 percent of calories from fat, HDL begins to slide.

Does that 30 percent figure sound familiar? It should. A diet that derives no more than 30 percent of calories from fat is what is now recommended by both the American Heart Association (AHA) and the National Cancer Institute for optimal health. Here's your eating plan for hitting that goal.

Eat lean. Choose skim, ½ percent or 1 percent milk and nonfat or low-fat yogurt and cheese. Eat no more than six ounces of cooked lean meat, fish or skinless poultry a day.

Prepare food without fat. Use cooking methods that require little or no fat--steaming, sautéing, baking, broiling, grilling and microwaving, for example. Trim all the fat you can see from any meat or poultry before cooking. Drain the fat after browning.

Use no more than two tablespoons of fat a day. Use as little fat and oils in cooking, baking and salad dressings as possible. Consider two tablespoons your max. Replace saturated fats--the kind that raise cholesterol--with monounsaturated ones found in canola oil and olive oil--the kind studies show actually help bring cholesterol down. Chill soups and stews after cooking, then skim off the hardened fat and reheat before serving.

Watch the cholesterol in foods. The watchword for cholesterol is this: Animal. Cholesterol is found only in animal foods, so if you want to cut down on your cholesterol intake, you need to limit your intake of meats, eggs and dairy products. These strategies should keep your dietary cholesterol to under 300 milligrams per day--the AHA's goal.

Drink moderately. No one wants to advocate alcohol use, so doctors are reluctant to say that alcohol boosts HDL. But research shows that women who drink moderately have HDL levels 6 to 18 percent higher than women who don't drink at all.

Obviously, common sense should prevail here. Since more than a glass a day of any alcoholic beverage can actually trigger other problems such as stroke or an increased risk of breast cancer, the fact that alcohol boosts HDL does not mean you should take up drinking if you've been a teetotaler all your life.

Eat clams, oysters and crabs. Once thought to escalate your cholesterol levels, these ocean dwellers have been found innocent of all charges.

The proof? In a study at the University of Washington in Seattle, a diet that included these three caused LDL cholesterol to sink 11 to 14 percent and HDL to rise 30 percent.

But don't try to extend the clean bill of health to other crustaceans. Although the study found that squid and shrimp had little effect on cholesterol levels, the researchers concluded that the amount of cholesterol in these two shellfish was still too high--280 milligrams in a 3 ½-ounce serving of squid and 157 milligrams in the same amount of shrimp--to be part of a heart-healthy diet.

Eat foods rich in vitamin C. Here's another reason that vitamin C is good for you: Studies have found that the vitamin C in oranges, cantaloupe, broccoli, brussels sprouts and other foods can help raise HDL.

But research also shows that if you have adequate vitamin C intake or are taking a supplement, taking more won't help. People with below-average vitamin C levels were the only ones whose HDL rose when they increased their vitamin C intake.