High Cholesterol

What Is Cholesterol? What Causes Excessive Cholesterol? Using Cholesterol To Measure Heart Disease Risk Understanding Triglycerides

Cholesterol And Triglyceride Levels Factors That Affect Cholesterol Levels Medications To Lower Cholesterol Levels

What Is Cholesterol?

Cholesterol may already be familiar to you as a risk factor for coronary-artery disease. But cholesterol is also vital to good health. Cholesterol is a type of a lipid, a soft, fat like substance that serves as a source of fuel and contributes to cell structure, the manufacturing of hormones and other biological functions. Cholesterol is manufactured by the liver. (In fact, your body manufactures all the cholesterol you need from other fats in your diet; you don't need to consume any cholesterol to maintain health.) You can also get cholesterol from consuming animal foods, such as meat, eggs and dairy products.

Too Much

Although cholesterol is vital to a variety of life-sustaining functions, too much cholesterol in your blood is a major risk factor for heart disease. Excessive cholesterol can cause buildup of atherosclerotic plaque. Accumulation of plaque in arteries can block blood flow and lead to a heart attack.

What Causes Excessive Cholesterol?

To understand how excessive cholesterol occurs, consider how cholesterol travels in your body. Cholesterol doesn't dissolve in water. Therefore, to circulate through your blood (which is mostly made up of water), cholesterol and triglycerides (another lipid in the blood) combine with proteins to form lipoproteins.

There are four types of lipoproteins, each differing in the ratio of cholesterol and triglycerides to protein. The main types are low-density lipoprotein (LDL) and high-density lipoprotein (HDL).

LDL cholesterol, the so-called "bad" cholesterol, is transported to sites throughout the body where it's used to repair cell membranes or make hormones. LDL cholesterol can accumulate in the walls of your arteries, just as hard water promotes a buildup of lime inside the plumbing of your house. Cholesterol deposits, however, are spotty, rather than evenly coated, throughout the arteries.

HDL, the so-called "good" cholesterol, is transported to the liver, where it's altered and removed from the body. In a sense, HDL is the clean-up crew that sops up excess cholesterol from the tissues and disposes of it before it can do any damage. In fact, there is no good cholesterol. It is the lipoprotein HDL that is "good," not the cholesterol it carries. But laboratories measure HDL cholesterol rather than HDL itself.

Using Cholesterol To Measure Heart Disease Risk

No single cholesterol or ratio of cholesterol numbers provides an absolute standard for measuring heart-disease risk. Your lipid profile includes the following measurements: total cholesterol, LDL cholesterol, HDL cholesterol and triglycerides.

Total cholesterol, LDL cholesterol, and HDL cholesterol reflect a dynamic process — cholesterol is deposited in the walls of blood vessels and then taken away. The total cholesterol level is the crudest look at this process; the LDL and HDL numbers give a more detailed look at the two-way traffic inside your blood vessels. Ideally, LDL cholesterol levels should be less than 100 milligrams per deciliter (mg/dL). An HDL cholesterol level under 40 mg/dL is low; a level of 60 mg/dL or above is excellent.

Understanding Triglycerides

Like cholesterol, triglycerides are lipids that circulate in your blood. Triglycerides are used by the body to transport and store fat. The relationship between high triglyceride levels and heart disease is complex; clearly, however, high triglyceride levels aren't good for health. High triglyceride levels accompanied by low HDL levels appear to be especially worrisome.

Cholesterol And Triglyceride Levels

Here is information for interpreting cholesterol and triglyceride levels, based on guidelines recently issued by the National Cholesterol Education Program Expert Panel.

LDL Cholesterol Less than 100 Optimal 100 to 129 Near optimal 130 to 159 Borderline high 160 to 189 High 190 or greater Very high

Total Cholesterol Less than 200 Desirable 200 to 239 Borderline high 240 or greater High

HDL Cholesterol Less than 40 Low 60 or greater High

Triglycerides Less than 150 Optimal

Factors That Affect Cholesterol Levels

Factors that affect cholesterol levels include diet, exercise and genetics.

Diet

Significantly large amounts of saturated fat and trans fat in your diet can increase your cholesterol levels, more so than anything else you eat. Saturated fat is found in animal foods such as meat, fish, poultry and whole-milk dairy products, such as cream, milk, ice cream and cheese. Saturated fat is also found in butter, lard and coconut, palm kernel and palm oils. Your body easily turns saturated fat into cholesterol, which ends up in the walls of your arteries.

Trans fats are fats that start out as liquid vegetable oils, and then are transformed by a chemical process (hydrogenation) into solids at room temperature. This process turns healthy vegetable oils into unhealthy fats that raise LDL cholesterol and lower HDL cholesterol.

If you are trying to modify your diet to improve your lipid profile, focus on reducing the amount of saturated fat and trans fat in your diet rather than the absolute amount of cholesterol.

Exercise

Regular aerobic exercise reduces your blood levels of triglycerides and increases your levels of beneficial HDL cholesterol.

Genetics

Your genes can affect your cholesterol levels. Because of abnormal genes inherited from their parents, some people lack certain cell receptors that are needed for removing LDL from the blood. In this condition, called familial hypercholesterolemia, people can have extremely high levels of LDL cholesterol. This results from inheriting one bad gene (these people are called heterozygotes) or two bad genes (called homozygotes). Heterozygotes can develop premature coronary-artery disease, usually in their 40s to 60s, whereas homozygotes can die of heart attacks in their teens or 20s. There are also milder forms of hypercholesterolemia, which generally produce moderate elevations of cholesterol and proportionally increased risk of premature heart attacks.

Medications To Lower Cholesterol Levels

Reducing your cholesterol and other levels of blood fats should begin with lifestyle changes, such as following a low-fat diet and controlling weight, but a number of drugs can lower total cholesterol, LDL and triglyceride levels, while increasing beneficial HDL levels. If your cholesterol levels are high despite dietary changes, talk to your doctor about how to reduce them with these lipid-lowering medications:

Drug Category: Statins
How They Work: Statins block the production of cholesterol.
Some Common Agents: Lovastatin, pravastatin, simvastatin, fluvastatin, atorvastatin, cerivastatin

Drug Category: Niacin
How They Work: Niacin reduces the liver's ability to produce very low-density lipoprotein, the precursor of LDL.
Some Common Agents: Nicotinic acid, niacin extended-release (Niaspan), niacin (Slo-Niacin)

Drug Category: Fibrates
How They Work: Fibrates activate an enzyme that speeds the breakdown of triglycerides in the blood.
Some Common Agents: Clofibrate (Atromid), gemfibrozil (Lopid), fenofibrate (Tricor)

Drug Category: Bile acid sequestrants
How They Work: These drugs bind with bile acids (which are made from cholesterol) in the intestines and remove them in the stool. More cholesterol is then used by the liver to make bile acids.
Some Common Agents: Cholestyramine, colestipol

Drug Category: Cholesterol absorption blockers
How They Work: They decrease total serum and LDL cholesterol levels by inhibiting absorption of cholesterol from the intestinal tract.
Some Common Agents: Ezetimibe (Zetia) is currently the only one approved from this category.

Lifestyle Changes

The lifestyle choices to keep your heart healthy are similar to what you should do to help prevent many other diseases, such as diabetes and certain types of cancer. If you have coronary heart disease or are at high risk to develop it, you should do the following:

• Eat plenty of vegetables and fruits while avoiding trans fats and saturated fats.
  
• Keep blood pressure in the normal range, ideally with a systolic blood pressure of less than 120 millimeters of mercury (mm Hg).
  
• Don't smoke.
  
• Get your low-density lipoprotein, or LDL (bad), cholesterol under 100 milligrams per deciliter (mg/dL) and perhaps as low as 70 mg/dL. This usually requires medications such as a statin drug.
  
• Maintain a healthy weight.
  
• Strive to keep your blood sugar levels normal.
  
• Manage stress.
  
• Become more physically active, and make daily exercise a priority at an intensity level recommended by your doctor.
  

High LDL cholesterol is one of the major risk factors for heart disease, and the risk increases as the bad cholesterol level rises. Other major risk factors are smoking, high blood pressure and diabetes. Your cholesterol level is determined by your genetic makeup and the amount of saturated fat and cholesterol in the foods you eat. The liver manufactures cholesterol, so even if you never eat cholesterol, your body can make all it needs.

Several factors contribute to high blood cholesterol:

Diet: Reduce your blood LDL cholesterol level by eating less fat, particularly saturated fat (as found in whole milk, cheese and meat). Low cholesterol foods are important, too. Studies have shown that your total cholesterol and your bad cholesterol levels may begin to drop two to three weeks after you begin your lower you intake of fat, calories and cholesterol.

A healthy diet:

• Contains healthy fats. Once you've cut way back on saturated fats and trans fats (the unhealthy fats), you can start adding healthy fats to your diet. Healthy fats are polyunsaturated and monounsaturated.
  
• Contains healthy sources of carbohydrates. Eat more whole grains — foods like whole-wheat bread, brown rice and oatmeal — to help lower cholesterol, improve blood sugar and insulin levels, control weight, protect the heart, guard against diabetes and keep your digestive system healthy.
  
• Relies on healthy sources of protein. For a healthier heart, cut back on red meat and switch to fish. Why? The good fats in many types of fish help protect the heart against erratic rhythms and may prevent blood clots. The American Heart Association now recommends that people eat fish (especially fatty fish) at least two times per week. Beans, nuts and seeds are also excellent sources of protein.
  
• Includes plenty of fruits, vegetables and whole grains. These foods have more powerful effects on your health than most pills.
  
• Tastes great. If it doesn't, you probably won't stick with it for long.
  

Weight control: Obesity increases triglyceride and total blood cholesterol levels, blood pressure and the risk of developing diabetes.

Exercise: Regular exercise may help a person control weight, lower blood pressure and increase the level of high-density lipoprotein, or HDL (good), cholesterol.

Genetic factors: Lowering your LDL cholesterol levels through diet often is not enough to reach your goal. Many people are genetically programmed to produce cholesterol in the liver no matter how strictly they follow a diet. They require cholesterol-lowering drugs to get their levels in shape.

Sex/age: Coronary heart disease is the leading cause of death and disability for both men and women in the United States. Traditionally, coronary heart disease has been associated much more with older men than women. However, today, the importance of lifestyle changes is recognized for both sexes at all ages.

Alcohol: In some people, modest amounts of alcohol can increase the amount of good cholesterol (HDL). Modest intake means two or fewer drinks per day for men and one drink per day for women. There is good evidence that moderate alcohol intake lowers the risk of coronary artery disease, whether or not the protection is due to increasing HDL levels. However, alcohol provides "empty calories" that can add to your weight. Because drinking can have serious adverse effects, present guidelines do not recommend drinking alcohol as a way to prevent heart disease.

Smoking: Smoking damages the heart by raising blood pressure, damaging blood vessels, promoting the buildup of fatty plaque in arteries, lowering levels of "good" cholesterol, making the blood more likely to clot and depriving the heart of oxygen. Quitting smoking is the best thing you can do to prevent a heart attack.

Stress: Stress can increase chemicals within the body that may increase the risk of a heart attack. These fight-or-flight stress hormones, such as cortisol and epinephrine, excite the heart and make it work overtime.

To Treat Depression, Take Action

• What is Behavioral Activation Therapy?
  
• Rx for Action
  
• Putting it All Together in Practice
  

I have always resented that commercial urging us to "just do it." For people with depression, it's insulting — and useless — because the smallest task can seem like a huge obstacle. There are many times in life when moving forward requires discomfort. Transitions from middle school to high school to college, or from one job to another, challenge us to master new skills. But people with depression sometimes have a tougher time during these periods. This is not because they are less capable than anyone else. It's because they have less confidence than the average person or have a talent for imagining the worst.

But the results of a new study show that, with the right kind of coaching, encouragement and education, action may be a pretty effective treatment for depression.

Earlier this year, a group of psychologists at the University of Washington compared four types of depression treatment: behavioral activation, cognitive-behavioral therapy, an antidepressant medication and a placebo pill.

They assigned about 250 people with major depression to one of the four treatment groups. After four months, patients in the behavioral activation (BA) group did at least as well as those receiving an antidepressant. The results were a surprise. Guidelines say that cognitive therapy and antidepressants are the most effective treatments for depression. In one way, BA was better than antidepressants — fewer patients receiving BA dropped out of treatment than those taking a pill. Also intriguing: among the most severely depressed patients, BA was more effective than cognitive therapy.

What is Behavioral Activation Therapy?

Behavioral activation is not a practice of telling patients to "just do it." It is, however, a technique that helps depressed people do what they tend to avoid.

Proponents of this type of therapy believe it works because depressed people tend to withdraw from stressful situations. They get some relief in the short run because they spare themselves the pain of confronting tough problems. But they also miss out on the rewards. For example, a depressed man may call in sick to avoid an unpleasant interaction with a co-worker. In the long run, however, he misses out on the satisfaction that could come from getting his job done and earning a living. And avoidance leaves the original problem unchanged. Inaction just makes problems worse and deepens depression so that getting out of bed in the morning becomes more difficult.

Logic is behind BA, not shaming or blaming the person for his problems. Depression usually makes people withdraw from activites that could be pleasurable, depriving a person of the satisfactions (environmental reinforcers) that come from engaging in life. So activity can help increase enjoyment in life and relieve depression. To encourage activities, the patient is taught to adhere to a daily schedule and gradually increase their activity. The therapist also tries to help the patient interrupt the circular, self-critical thinking associated with depressed feelings and pay attention to the present moment and actions that help reach long-term goals. Improving problem-solving skills makes up the third part of BA.

Behavior therapy and cognitive therapy differ in important ways. A cognitive therapist will spend time reviewing negative and distorted thinking and self-defeating beliefs. According to the cognitive therapy model, thinking must change before behavior can. A behavior therapy model such as the BA technique asks the patient not to think too much. It focuses on simple strategies such as goal-setting, problem-solving, and attending to the task at hand, rather than on the overwhelming big picture. The two approaches have been closely linked for many years through an approach called cognitive-behavior therapy (CBT), which purposely blends the two.

Rx for Action

A happier life does not depend on a victory of "just do it" over "getting in touch with your feelings." The answer, as usual, lies somewhere in the middle. You don't want a life of grinding through tasks without feeling anything. The trick is to turn your attention away from thoughts and feelings that undermine your functioning, and toward thoughts that promote it. Proponents of behavioral activation ask their patients to notice when they are dwelling on unproductive thoughts and focus instead on the immediate sights and smells they're experiencing around them. Once you begin to function better, it's easier and more useful to begin to examine your thoughts from a position of strength and understand why they were so negative in the first place.

Taking action is not easy for a depressed person to do on his or her own. So a therapist has to be the encouraging coach or personal trainer who reminds a patient of the good that will come from doing difficult things.

Putting it All Together

Overall, behavioral activation was the most effective treatment in the University of Washington study. Behavioral activation should not replace CBT and antidepressant medication as the first treatment recommended for depression. But this study demonstrates the value of including BA in a comprehensive plan for treating depression, especially in its most severe forms.

In practice, you don't have to choose one technique over the other. You can use whatever you need. Research on depression treatment has shown that combining approaches gives patients the best chance to feel better and do better. For most people, behavior activation should be added into a mix of psychotherapy techniques, along with the judicious use of antidepressant medication. In other words, don't "just" do it — do it all.

Using Spirituality To Ease the Mind

• Religion and Spirituality in America
  
• Spirituality in Mental Health Treatment
  
• Starting the Discussion
  
  

As December leads into a new year, enthusiastic holiday preparations are supposed to lead to joyful family celebrations. Typically, however, this time brings as much stress as pleasure.

Given that all the major holidays of the season have spiritual origins, it may be worth thinking about how to use spirituality and religion for support, particularly if you are considering seeing a therapist or are already seeing one.

Many people assume that spirituality and religion have to be kept out of the therapist's office. But more and more clinicians realize that it can be helpful for patients to talk about their spiritual and religious beliefs.

Religion and Spirituality in America

Certainly, religion is an important part of American life. The Pew Forum on Religion and Public Life reports that 87% of Americans consider themselves to be religious, while 57% attend some type of worship service on a regular basis.

Likewise, a Newsweek/Beliefnet poll found that 88% of Americans who responded described themselves as spiritual, religious or both.

There's no way to know how many respondents were struggling with their mental health, but I assume that many of them turned to their spiritual practices for comfort, particularly if they were working hard to manage severe and ongoing problems such as addiction, unusual stress or mental illness. Moreover, as a way to enhance psychotherapy, understanding a person's spirituality may provide helpful insights into his or her value system or relationships.

Spirituality in Mental Health Treatment

Clinicians working in hospitals, mental health centers and other participating organizations are required by The Joint Commission — an independent organization that accredits and certifies more than 15,000 health care organizations and programs in the United States — to do a "spiritual assessment" of patients' spiritual beliefs and practices. The information is intended to improve treatment and services.

Critics of the regulation say that a spiritual assessment may not be as important in highly technical aspects of medical care — for example, cardiac surgery — as it is in primary care or mental health. Moreover clinicians in private practice don't have to adhere to The Joint Commission requirements.

Many patients receiving counseling may want their spiritual beliefs to be taken into account as part of their treatment. If this is important to you, it's helpful if the person treating you:

• Asks about your spiritual beliefs without judging them. Then your spiritual beliefs can become part of the treatment plan, according to The Joint Commission. A therapist doesn't have to come from the same religious community as you. What's more important is that the clinician is comfortable discussing these matters, takes your views seriously and can discuss them with you sympathetically.
  
• Is curious about your spiritual beliefs, is willing to learn about them, and — when it's helpful — to consult with clergy. If your therapist doesn't know very much about your particular religious practice, it's more difficult for him or her to know how best to help you. If the clergy or spiritual leaders that you have a relationship with would be willing to talk with your therapist, suggest to your therapist that he or she speak with them.
  
• Is prepared to make spirituality part of the treatment plan. It's very helpful for the therapist to find a way to make spirituality part of your recovery plan along with support, medication and psychotherapy. For example, if you are a practicing Catholic who is struggling with an addiction, you may find it helpful to attend Mass on a daily basis rather than weekly.
  

Starting the Discussion

If you're wondering how to get the conversation about spirituality going with your therapist or doctor, it may help to start by explaining your religious practices. Of course, it is up to your therapist or doctor to put you at ease so you can talk about these things. If religion is an important part of your life and your therapist is not interested in hearing about it, consider consulting someone else who is.

Here are some useful topics to talk about:

• How you express your spirituality
  
• How important prayer is to you
  
• Who, as a spiritual leader or clergy member, is particularly important to you and can be a resource if the therapist has questions
  
• How often you attend some type of religious service and how the practice of religion fits into your daily life
  
• How you find inner strength to deal with suffering and adversity; if you rely on a particular person, or follow a specific practice to gain strength
  
• Your specific spiritual goals
  
• How faith helps you cope with illness and suffering
  
• What type of spiritual support you want as part of your treatment plan
  

If spiritual matters are meaningful to you, you probably won't want to talk about them only during the month of December. With a little planning, your religious practice does not have to compete with your mental health treatment. Instead, you and your therapist can find the best ways to use it as a tool to enhance your life all year long.