Cholesterol and Triglycerides Levels

Do You Know Your Ratio and Cholesterol and Triglyceride Levels?

“How do I know how much fat has already been deposited inside my coronary arteries?” you may wonder.

Most people don’t think about this until something happens to them. They may experience a tightness, heaviness, some unusual discomfort (rarely would it be called a pain) in their chest, or just get very short of breath. Eventually, they realize they have to get medical care.

A doctor usually begins by doing a simple electrocardiogram on you. Twenty-five percent of heart attacks are silent but show up on a routine electrocardiogram. If the resting electrocardiogram is normal, the next step is to do a treadmill test. An electrocardiogram is done while you exercise. For people who can not exercise, some doctors will inject a medicine, dipyridamole (Persantin®), which makes your heart race.

If your heart arteries (coronaries) are clogged, when your heart rate increases, not enough blood will be delivered to your heart muscles. This changes your electrocardiogram in a characteristic way described as the ST (part of the tracing) depression or elevation. At this time, thallium or some other isotope may be injected into your arm vein and the heart will be scanned to see what part of your heart muscle is not receiving blood. Most people return about 2 to 4 hours (or longer) after the first scan to see if the blood-flow “deficit” is permanent.

If the deficit is permanent, it could mean the part of the heart muscle that was not receiving bloopd may have died. In any event, it usually means that a blockage exists in one of your coronary arteries and so doctors go to the next step to find out where the blockages are and how much. This requires that a catheter be inserted into an artery in your groin and run up the big arteries in your stomach and chest to the arteries of the heart. A radio-opaque dye is injected which allows your doctor to see where the blockages are.

A new procedure called Ultrafast CT (Computerized Tomography) scan only takes 6 minutes while you are lying down. With this test, doctors can see many of the deposits located on the arteries of your heart. An even newer procedure using Magnetic Resonance lets doctors look inside your arteries without having to use a catheter.

However, this is only part of the story when you realize that your first or next heart attack doesn’t usually come from big blockages in your arteries that reduce blood flow, but rather from deposits of soft fat, usually in the valleys between the large blockages. These soft deposits are covered by only a thin layer of cells. This layer ruptures and causes a massive blood clot to form, producing a heart attack. We are only beginning to find ways to see these deposits before they grow into the kinds of deposits that block blood flow. When people lower the bad kind of cholesterols, or the bad triglyceride-rich particles in their blood, the first particles to shrink are these soft plaques.

Get a Blood Test

There is something everyone can and should have checked right now. How much fat is floating around in your blood. A set of blood tests (called a lipid panel) tells about the risk of your coronary arteries getting plugged up.

Is there an easier way to see these soft or large plaques forming inside your coronary arteries? Not directly, but we may get a clue by doing a scan (ultrasound or Ultrafast CT) to see if plaque is forming in the big arteries-the carotids-that carry blood to your brain. “So what?” you may be thinking. “What does plaque in one’s carotids have to do with plugging in a person’s coronary arteries?”

Exciting pioneering work at Framingham shows that 76% of people older than 65 already have lesions in their carotids big enough to show up on a scan. Some of these lesions are just a thickening of the artery wall and others are deposits of fat. If there is plaque in your carotid arteries, we can be almost certain there is plaque in your coronary arteries. We believe scanning testing for arterial plaque will become a very helpful and widely used procedure as time goes along. At this point, carotid scans are not a routine procedure for those with suspected coronary-artery disease.

Do You Know Your Cholesterol and Triglyceride Numbers?

We say numbers instead of number because there are 18 different kinds of cholesterol-most bad, some good and a very important ratio.

It all begins by having your total cholesterol and HDL cholesterol measured. These two cholesterol measures can be done without fasting (non-fasting). Doctors and patients should never again waste their time or money measuring the total cholesterol alone.

Look first at your total cholesterol. Is it under 150mg/dl (3.8mmol/L)? If so you should get your 2 miles in a day and eat a low-fat diet so you lower your risk of colon cancer, gall-bladder disease, or breast cancer. Your chances of getting a heart attack are slim.

If your total cholesterol reaches 150 (3.8) then you must make a simple ratio. Divide the total cholesterol by the HDL cholesterol. Suppose your total cholesterol was 200 and your HDL cholesterol was 50, your ratio would be 4.

Total cholesterol / HDL Cholesterol = Ratio

If your ratio is higher than 4 you are continuing to increase the deposits of fat in your arteries. You need to start your diet and exercise program to lower this ratio to under 4 to stop the progression of the cholesterol sludge in your arteries.

If you have had a heart attack, stroke or some artery blockage and want to shrink the deposits of fat you have to get your ratio under 3. But in order to know whether you have a nasty LDL cholesterol problem, a nasty triglyceride problem or both we need to do further testing.

If your total cholesterol reached 150 and your total cholesterol/ HDL cholesterol ratio was 4 or higher you must have your blood fats retested after fasting 12 to 14 hours, where we measure the total cholesterol, HDL cholesterol and triglycerides.

If your total cholesterol is 150 or higher and your total/HDL cholesterol ratio is 4 or higher, look at your triglyceride number. If it is under 150 (1.7) you have nasty LDL. You have too much LDL cholesterol for the HDL cholesterol you have.

If your triglyceride is 150 or higher with that bad ratio over 4 you have high triglyceride and low HDL cholesterol, the hallmark of Reaven’s Syndrome X, Kaplan’s deadly quartet, Williams’ Dyslipidemic Hypertension, Defronzo’s insulin-resistance syndrome, or the Polymetabolic Syndrome.

Much of our knowledge of how cholesterol relates to coronary-artery disease comes from studies like the Framingham Heart Study and a few other well designed clinical trials. As you can see in Figures B and C, at virtually any age the heart-attack rate rises 2% for each 1% the level of total cholesterol in the blood goes up. This is even true for people over 65.

The average total cholesterol level of a man in the Framingham Heart Study who had a heart attack in the first 16 years of the study was 244. Now, some 33 years later, that level is about 225. In general, the higher this total cholesterol is, the more likely a person is to have a heart attack.

Some people in the Framingham Study who had high cholesterol levels didn’t have heart attacks. The trick is to know where you stand if you have a high (or even not so high) total cholesterol level. Are you headed for a heart attack-or will you escape?

The Framingham Heart Study

An ongoing in-depth study was begun in 1948 with 5127 men and women in the town of Framingham, Massachusetts to evaluate the risk factors of coronary artery disease. The test subjects represented one half of all the healthy adults-men and women-in that town. From then till now, they have been examined and checked every two years. Since then, other generations of Framingham people have joined the study. In a way, this study is a “gift” from the people of Framingham to the world.

Heart attacks, deaths and laboratory data have been carefully followed, providing valuable information about the risk factors related to coronary-artery disease. After careful analysis of the data from Framingham, as well as collaborative studies from across the U.S., Finland and other countries, there isn’t any question that high cholesterol levels result in more heart attacks. Summing up these results shows that a 1% rise in cholesterol increases the chance of coronary artery disease by 2% in both men and women.

Co-author William P. Castelli was the Medical Director of the Framingham Heart Study of The National Heart, Lung and Blood Institute from 1979 until 1995.

Total Cholesterol Doesn’t Tell Everything

The answer begins by knowing your cholesterol numbers. But your blood level of total cholesterol provides only one clue about what your body does with the saturated fat and cholesterol you eat. It’s just one clue because there are 18 different kinds of cholesterol and other fats (lipids) in the blood-and they are not all bad. As we will show, measuring total cholesterol, HDL cholesterol and triglycerides allows us to make a good estimate of how you are doing.

A home cholesterol test kit or a cholesterol “screening test” at a shopping mall only measures total cholesterol. Although these tests may help to identify people with a very high total cholesterol, they miss people at risk whose cholesterol level may seem OK. We advise against relying on these simpler tests because they do not provide all of the information you and your doctor need. When your total cholesterol is between 150 and 300 (and that is about 90% of the people 30 years or older), we can’t tell whether you are in the group to get a heart attack or stay free of an attack.

Most doctors follow the guidelines recommended by the National Cholesterol Education Program which recommend that everyone start by measuring their total and HDL cholesterols. Both tests can be done without fasting, so this is a very convenient way to start.

Now you can look at the major fat-containing players in your blood:

1. total cholesterol
2. LDL cholesterol
3. HDL cholesterol
4. triglycerides

Good (Healthy) Cholesterol (HDL)

One of the things a good group of blood tests will tell you is your level of good cholesterol, called HDL, short for High Density Lipoprotein. (The H in HDL can remind us this is Healthy cholesterol.)

Bad (Lousy) Cholesterol (LDL)

There is a harmful cholesterol called LDL, short for Low Density Lipoprotein. (The L in the LDL can be a reminder this is Lousy cholesterol.)

If you don’t have a vascular or heart problem and no other risk factors, get your LDL cholesterol under 160 (4.1).

If you are free of clinical disease but have two other risk factors (Family history of heart disease under age 55, hypertension, cigarette smoking, diabetes, HDL less than 35) then you need your LDL under 130mg/dl (3.4mmol/L). If you have had a heart attack or other vascular problem you must get your LDL under 100 (2.6).

Triglycerides

Triglycerides are the most common form of fat in the diet-and in the human body. Too much of these fats put a person at risk for pancreatitis- inflammation of the pancreas - as well as increased risk of getting a heart attack. Triglycerides are carried in the very-low-density lipoproteins (VLDL), which we can add to the other lousy lipoproteins. High triglycerides can cause plugged-up coronary arteries even if the cholesterol levels are normal.

Most (about 70% in North America) of the triglycerides, a different kind of fat than cholesterol, are carried in small particles in your blood. These particles can also be deposited on the walls of your arteries. Because these particles also contain cholesterol, they add to the burden of cholesterol in your blood. These particles increase in our blood when we eat too much saturated fat and cholesterol and get fat.

In addition, with high triglycerides, our blood is more likely to clot, pressure our insulin goes up, our HDL cholesterols fall and our blood goes up.

Another type of triglyceride-rich particle also can go up in our blood from eating too much refined carbohydrates (white flour, sugar), and while there is less tendency for these larger particles to be deposited in our blood vessels, they are usually associated with an increased tendency of our blood to clot. They also are associated with a fall in HDL cholesterol.

If your triglyceride is 150 or higher at the same time your HDL is 45 or less, you have the small triglyceride particles and a fast road to vascular disease; whereas if your triglycerides are high with high HDL cholesterol, you have the larger, somewhat less dangerous kinds of triglycerides. The large kind of triglyceride particles are also increased by drinking too much alcohol, taking estrogen, or taking the resin medicines Colestipol or Questran.

This brings up another problem. Not everyone, even good health-care professionals and official organizations, understands the seriousness of high triglycerides. Figure G shows a definite relationship between high triglyceride levels and coronary-artery disease. Dr. Castelli tracked triglyceride data carefully over many years in the Framingham Heart Study and the evidence leaves no doubt.

The higher the level of triglycerides in the blood, the higher the heart-attack rate in every study. No matter what anyone may say to the contrary, people with high triglycerides-even with normal cholesterol levels-can and do have heart attacks from plugged-up coronary arteries.

Dr. Griffin knows this from the personal experience of having had bypass surgery after a 98% blockage in one coronary artery and an 80% in another, resulting from high triglycerides with a perfectly normal total cholesterol level.

Sooner or later, the danger of high triglycerides will be universally recognized. While the official word is that triglycerides may be a problem, there is absolutely no question about it. High triglycerides are a big problem.

The Cholesterol Ratio

This leads to another number we want you to know. We’re not going to expect you to remember many numbers, but this one is important. It is your ratio which is simply your total cholesterol divided by your HDL level.

A safe ratio is 4 or less. Anything higher means your risk for having a heart attack goes up. In fact, Figure H clearly shows, the higher the ratio, the greater the risk. This is why the ratio is so important.

As the solid evidence at the Framingham Heart Study has shown over many years, what someone’s total cholesterol happens to be does not tell the full story. The significance of high total cholesterol really As we depends on how high or low the HDL cholesterol is in a person. explained, HDL is the Healthy or good cholesterol. The good thing is that if a person has enough HDL, it is somewhat protective against the damaging effects of an elevated LDL or total cholesterol. As is conclusively evident in Figure F, the higher a person’s HDL level, the lower the incidence of a heart attack.

On the other hand, if a person has a very low HDL level, even with a normal cholesterol level, they may be at considerable risk. This means that someone with a very low HDL may be at even greater risk than someone who has a higher total cholesterol level but who also has a relatively high HDL level. The only time we don’t care about your HDL or your ratio, is if your total cholesterol is under 150.

For example, let’s say a person has a total cholesterol level of 170, considered by many to be perfectly normal. If that person has an HDL level of 32, she would have a dangerously high ratio of 5.3, meaning the person is at great risk for accumulating fat plaques and having a heart attack. (If you are in Canada, Europe or anywhere else where the mmol/L numbers are used, the ratio works out exactly the same— 4.2-0.78 = 5.3).

Suppose another friend has a seemingly normal total cholesterol of 180 and an HDL level of 30. The ratio is 6-even higher than the previous example. Both persons need to get on aggressive programs to help get their lipids under control.

Everyone agrees that an HDL level should at least be above 35, but not everyone understands the importance of the relationship of the HDL to the total cholesterol.

Consider a friend with a total cholesterol of 250-well into the range that most people consider as being in a high-risk range for having a heart attack. Most of the time, this would probably be so. Now suppose this friend’s HDL level was 65-quite a bit of Healthy cholesterol. The ratio comes out to be 3.8, which means your friend is really not at high risk. She has enough good HDL cholesterol to help protect her against the high levels of the bad cholesterol.

Understanding the relationship of HDL to total cholesterol explains why well-intended guidelines, based only on knowing a person’s total cholesterol, do not provide enough information.

Many people believe anyone with a total cholesterol level under 200 is safe and not at risk. Surprisingly, the word in the original guidelines describing cholesterol levels under 200 was “desirable.” At first, these guidelines went on to say that those with cholesterol levels between 200 and 240 are borderline-high. Just suppose a person has a total cholesterol level of 210 and an HDL level of 30. Dividing 210 by 30 gives a ratio of 7. There is nothing borderline about this person’s risk, he is in a high-risk range.

Syndrome X

Here is a little more information about the “Deadly Syndrome X” (first mentioned on page 21), a combination of high triglycerides, low HDL (sometimes increased LDL), increased blood pressure, an increase in many clotting factors, increased uric acid and a blood sugar that starts to climb, often along with weight gain. This is often noticed as a spare tire spread around the middle. Anyone with an elevated triglyceride level and low HDL level should watch for weight gain and symptoms of diabetes (increased thirst, hunger and frequency of urination) or a gradually increasing fasting blood-sugar level.

Syndrome X is of such concern that a fasting blood-glucose level over 100 should be taken seriously in those with high triglycerides and a low HDL. To make this combination of difficult problems even worse, insulin levels rise in these people, putting them on the fast track to diabetes. When there has been a gain in weight, often trimming off just 15 pounds will make a big difference. Controlling each of the factors in this killer syndrome is extremely important.

Think how much money would be saved if we could discover all the people at risk for heart attacks and get them on the sensible program we are presenting in this book. The costs of intensive care in a coronary-care unit, angiography and angioplasty or open-heart bypass surgery for those who get coronary disease far exceed the costs of tracking down those at risk, helping them change their lifestyles and giving them lipid-lowering medications.

Let’s talk about the people in your own home. We are going to help you—and every member of your family-decrease the risk of a heart attack. Here are the few easy numbers we want you to remember. Beyond remembering these numbers, we want you to get your numbers at these levels:

Total cholesterol

150 or less is ideal; if yours is above 150, you need to look at your total-to-HDL cholesterol ratio

Ratio of total cholesterol/HDL

Less than 4 (less than 3 for those with vascular or heart disease)

LDL

130 (or 100 for those who have vascular or heart disease)

Triglycerides

150 (or 100 for those who have vascular or heart disease)

Making Sense of the Official Guidelines

Under the earlier official National Cholesterol Education Program guidelines, if your total cholesterol was over 240 or if you were in a borderline group between 200 and 239 and had two risk factors, you may have been sent to have your LDL checked.

1. Your chance of coronary-artery disease and a heart attack increases significantly if you have any two of these risk factors:
2. you are a male (or a female over age 50)
3. you have high blood pressure
4. you smoke
5. someone in your family has had a heart attack under the age of 55
6. your HDL cholesterol is under 35
7. you have diabetes mellitus
8. you are overweight

If your LDL was under 130, you were probably told you are at low risk and to follow a prudent diet, exercise and not to smoke.

If your LDL was over 160, you were probably told this is really bad and were instructed to go on a low-saturated-fat, low-cholesterol diet as we suggest!

You’ve just read a lot of numbers. As Figure D clearly shows, there isn’t any question that the higher the LDL, the higher the risk of coronary-artery disease. Almost everyone agrees that keeping your LDL under 130 is good and that an LDL over 160 is way too high.

What about the people in between? We are concerned about the many people who are lost in the confusion.

You can see how much better and simpler it is to follow our suggestions about using your total cholesterol, ratio and triglyceride level to know how much risk you are at now and along the way. Where did these other confusing guidelines come from?

For a long time almost no one paid much attention to someone’s cholesterol level-unless it was over 300, which was far too high.

To put this in perspective, when you were born, your total cholesterol level was about 70. Then, when you started eating, it went up to about 150 by your first birthday. As children in North America keep eating lots of fat, their average cholesterol goes up to about 160. This level usually then stays about the same until a person is about 17. Then, in cultures like ours, the level usually starts going up again until it reaches an average adult level of about 210 to 220. This average level is far from healthy.

Most people around the world don’t have cholesterol levels this high. People in parts of the world who don’t eat as much bad fat and who don’t get coronary-artery disease have total-cholesterol levels at or under 150. Of the 5.7-billion people on the earth, 4 billion are not at risk for the heart disease that kills half of North Americans. The average cholesterol of the people in central China is 125. The Masai in Africa have an average cholesterol of 135. In Latin America, outside the big cities, the average cholesterol is 140. Unfortunately, only 5% of North Americans over age 30 have a cholesterol level under 150.

And while most adults around the world have cholesterol levels under 150, half the children in the United States and Canada already have a cholesterol level higher than that.

You can see how the cholesterol problem became compounded when few were paying attention to a person’s cholesterol unless it was over 300. We know from studies like the Framingham Heart Study that most people in our population who get a heart attack have a cholesterol level between 200 and 250. Remember, this is what has been called a borderline range.

But back to the origin of the guidelines. Although obviously well-intended, they did not go far enough. At a time when few physicians knew what levels of cholesterol were cause for concern and most people knew next to nothing about the part played by the saturated fat they were eating, something certainly had to be done.

So, The National Heart, Lung and Blood Institute, part of the National Institutes of Health, formed a group called The National Cholesterol Education Program to get the message to the public. The first thing they set out to do was to decide what cholesterol levels were too high. Then this panel began a major campaign all over the country so everyone would understand they needed to know their blood cholesterol level.

The National Cholesterol Education Program provided a great service in making people aware of the dangers of elevated cholesterol and in bringing cholesterol-screening campaigns to towns all across the United States. This was a very important preventive health measure. We believe they should have gone a little further.

We realize that with the average cholesterol level in the U.S. running between 210 and 220, it would have been hard for the panel to announce guidelines saying that over half the population was at high risk, which was the actual truth.

The National Cholesterol Education Program was designed to uncover the bulk of people who would get coronary-artery disease unless they made drastic changes. As we pointed out, half the people who have heart attacks have a total cholesterol level under 225. More people with a cholesterol level of 225 get heart attacks than at any other level! In North America, 35% of the heart attacks occur in people who have a cholesterol level under 200. So, as helpful as the official guidelines have been, they have missed a lot of people who are at risk.

Our recommendations go beyond those of The National Cholesterol Education Program’s expert panel. We commend them for making the bold recommendations they did at the time-and the steps taken to improve them.

Obviously, judgment calls had to be made on the recommended numbers (levels). The economic and social impact of these decisions and recommendations probably weighed on the minds of the panel members as they made these decisions. These are very important considerations. Just imagine the economic effect that the panel’s recommendations have already made, such as the costs for the testing equipment and supplies, as well as the technicians, physicians and others involved in obtaining and interpreting the results.

The impact on the food industry is mind-boggling. A drastic cut in the saturated fat we eat has affected almost every aspect of the food industry from production to groceries, markets, restaurants and especially the big fast-food business.

What is the Best Triglyceride Level?

Probably because of the economic reasons, the panel’s current official policy is that any level of triglycerides under 200 is considered normal This recommendation is better than saying that triglyceride levels under 250 are normal, which was the original official recommendation. A level of 200 is still too high. Sooner or later it will be generally accepted that triglyceride levels should be under 150, with possibly a few exceptions.