Diseases

Whether elevated triglyceride levels in the blood lead to atherosclerosis and heart attacks is controversial. While abnormally high triglyceride levels may be a risk factor for atherosclerosis, it is difficult to conclusively prove that elevated triglyceride by itself can cause atherosclerosis. Elevated triglyceride levels are often associated with other conditions that increase the risk of atherosclerosis including obesity; low levels of HDL cholesterol; insulin resistance; poorly-controlled diabetes; and small, dense LDL cholesterol particles.

Lowering LDL cholesterol is currently one of the primary public health initiatives preventing atherosclerosis and heart attacks.The benefits of lowering LDL cholesterol are:

• Reduces or stops the formation of new cholesterol plaques on the artery walls
• Reduces existing cholesterol plaques on the artery walls and widening the arteries
• Prevents the rupture of cholesterol plaques, which initiates blood clot formation and blocks blood vessels causing heart attack or stroke
• Decreases the risk of heart attacks
• Decreases the risk of strokes
• Decreases the risk of peripheral artery disease

The same measures that decrease narrowing in coronary arteries also may benefit the large arteries in the neck and brain (carotid and cerebral arteries) as well as the femoral arteries that supply blood to the legs and the arteries that supply blood to the intestine.

Diet is the first step in treating hypertriglyceridemia. A low-fat diet, regular aerobic exercise, loss of excess weight, reduction of alcohol consumption, and stopping cigarette smoking may be enough to control triglyceride levels in the blood. In patients with diabetes, meticulous control of elevated blood glucose is also important. This can be monitored by measuring the hemoblobin A1c levels in the blood.When medications are necessary, fibrates (such as gemfibrozil [Lopid]), nicotinic acid, and statin medications can be used. Lopid not only decreases triglyceride levels but also increases HDL cholesterol levels and LDL cholesterol particle size. Nicotinic acid lowers triglyceride levels and increases HDL cholesterol levels and the size of LDL cholesterol particles.Statins are effective for decreasing triglyceride and LDL cholesterol levels and, to a lesser extent, elevating HDL cholesterol levels.

Therapeutic lifestyle changes to lower cholesterol“It must be emphasized that lifestyle modification (i.e., adhering to a heart healthy diet, regular exercise habits, avoidance of tobacco products, and maintenance of a healthy weight) remains a critical component of health promotion and ASCVD risk reduction, both prior to and in concert with the use of cholesterol-lowering drug therapies.”- 2013 ACC/AHA Guideline on the Treatment of Blood Cholesterol to Reduce Atherosclerotic Cardiovascular Risk in Adults

• Therapeutic lifestyle changes to lower LDL cholesterol can help lower and maintain levels naturally. This may involve
  • excess weight loss,
  • getting regular exercise, and
  • eating a heart healthy diet low in saturated fat and cholesterol.
• Medications to lower cholesterol: Medications are prescribed when lifestyle changes cannot reduce the LDL cholesterol to desired levels. The most effective and widely used medications to lower LDL cholesterol are called statins. Research has shown that only these statin drugs have a proven benefit to decrease the risk of heart attack and stroke. Other medications that have been prescribed to lower cholesterol profiles include fibrates such as gemfibrozil (Lopid), resins such as cholestyramine (Questran), and ezetimibe (Zetia).
  • Newer medications, PCSK9 protein antibodies, Alirocumab (Praluent) and evolocumab (Repatha) are potentially useful in treating certain patients where diet and statins have failed to adequately lower LDL level.

• The first step in increasing HDL cholesterol levels (and decreasing LDL/HDL ratios) is by implementing and maintaining therapeutic life style changes.
• Regular aerobic exercise, loss of excess weight (fat), and smoking cessation will increase HDL cholesterol levels.
• Regular alcohol consumption in moderation (such as one drink a day) will also raise HDL cholesterol. Because of other adverse health consequences of excessive alcohol consumption, alcohol is not recommended as a standard treatment for low HDL cholesterol.

The reduction of LDL cholesterol is only part of the battle against atherosclerosis. Individuals who have normal or only mildly elevated LDL cholesterol levels can still develop atherosclerosis and heart attacks even in the absence of other risk factors such as cigarette smoking, high blood pressure, and diabetes.

There are no established "normal" blood levels for total and LDL cholesterol. In most other blood tests in medicine, normal ranges can be set by taking measurements from large number of healthy subjects. The normal range of LDL cholesterol among "healthy" adults (adults with no known coronary heart disease) in the United States may be too high. The atherosclerosis process may be quietly progressing in many healthy children and adults with average LDL cholesterol blood levels, putting them at risk of developing coronary heart disease in the future.

The total cholesterol to HDL cholesterol ratio (total chol/HDL) is a number that is helpful in estimating the risk of developing atherosclerosis. The number is obtained by dividing total cholesterol by HDL cholesterol. (High ratios indicate a higher risk of heart attacks, whereas low ratios indicate a lower risk).High total cholesterol and low HDL cholesterol increases the ratio and is undesirable. Conversely, high HDL cholesterol and low total cholesterol lowers the ratio and is desirable. Ideally, one should strive for ratios of 2 or 3 (less than 4).

Triglyceride is a fatty substance that is composed of three fatty acids. Like cholesterol, triglyceride in the blood either comes from the diet or the liver. Also, like cholesterol, triglyceride cannot dissolve and circulate in the blood without combining with a lipoprotein.The liver removes triglyceride from the blood and it synthesizes and packages triglyceride into VLDL (very low-density lipoprotein) particles and releases them back into the blood circulation.

High triglyceride blood levels (hypertriglyceridemia) may be genetic or they may be acquired. Examples of inherited hypertriglyceridemia disorders include mixed hypertriglyceridemia, familial hypertriglyceridemia, and familial dysbetalipoproteinemia.Hypertriglyceridemia can often be caused by nongenetic factors such as obesity, excessive alcohol intake, diabetes mellitus, kidney disease, and estrogen-containing medications such as birth control pills.

A healthy diet that minimizes cholesterol intake is a good first step in using food to decrease cholesterol levels in the blood. Extra lean meats, skim milk, and vegetable-based "butter-like" substitutes may help decrease LDL levels in the bloodstream.In addition to diet, exercise, and weight loss, there are foods that may help in lowering and rebalancing the cholesterol -- increasing HDL (the good) and decreasing LDL (the bad).Increasing soluble fiber in the dietIncreasing soluble fiber in the diet helps decrease both total cholesterol and LDL cholesterol. Sources include:

• oatmeal,
• oat bran,
• a variety of vegetables and fruits: beans, apples, pears, barley, and prunes.
• The goal for consumption of dietary fiber is 5 to 10 grams of soluble fiber a day (a cup of oatmeal has 4 grams of fiber and an apple contains 3 grams).

Olive oil

• Olive oil acts as an antioxidant to decrease LDL levels and does not affect levels of good HDL cholesterol.

Foods fortified with plant sterols and stanols

• Foods fortified with plant sterols and stanols decrease cholesterol absorption in the intestine. They can be found in cereal, margarines, and yogurts. Read labels to discover which foods are fortified with these beneficial plant compounds. Sterols and stanols may also be found as a dietary supplement.

SoySoy and foods containing soy products may help decrease LDL levels.NutsNuts are healthy. Almonds, hazelnuts, peanuts, pecans, pine nuts, pistachios, and walnuts may be helpful in decreasing cholesterol levels. However, nuts are high in calories and should be eaten in moderation. Also, one should avoid nuts covered with salt or sugar.Omega-3 fatty foodsCertain fish contain omega-3 fatty acids that lower cholesterol levels. The American Heart Association recommends at least 2 to 3 servings per week in the diet. Fatty fish that are helpful include salmon, halibut, mackerel, trout, herring, and sardines. It's best to grill or bake fish and to avoid frying.

• Cholesterol is a chemical compound that is naturally produced by the body and is structurally a combination of fat (lipid) and steroid.
• Cholesterol is a building block for cell membranes and for hormones like estrogen and testosterone.
• About 80% of the body's cholesterol is produced by the liver, while the rest comes from our diet.
• The main sources of dietary cholesterol are meat, poultry, fish, and dairy products. Organ meats, such as liver, are especially high in cholesterol content, while foods of plant origin contain no cholesterol.
• After a meal, dietary cholesterol is absorbed from the intestine and stored in the liver.
• The liver is able to regulate cholesterol levels in the bloodstream and can secrete cholesterol if it is needed by the body.

Lipid-altering medications are used to lower blood levels of undesirable lipids such as LDL cholesterol and triglycerides and increase blood levels of desirable lipids such as HDL cholesterol. Several classes of medications are available in the United States, including HMG-CoA reductase inhibitors (statins), nicotinic acid, fibric acid derivatives, and medications that decrease intestinal cholesterol absorption (bile acid sequestrants and cholesterol absorption inhibitors). Some of these medications are primarily useful in lowering LDL cholesterol, others in lowering triglycerides, and some in elevating HDL cholesterol. Medications also can be combined to more aggressively lower LDL, as well as lower LDL and increase HDL at the same time.Newer medications, alirocumab (Praluent) and evolocumab (Repatha), have been approved to help lower LDL levels in certain pateints where diet and other statin medications have not worked adequately.Note: Dosing guidelines change. The U.S. Food and Drug Administration (FDA) issued a guideline concerning the potential dangers of taking the 80 mg dose of simvastatin (Zocor).