Are you (or your doctor) following cholesterol guidelines set-forth by the National Cholesterol Education Program (NCEP) focusing on lowering LDL or "bad" cholesterol? If so, you will be surprised to learn that these experts who recommend "preventive" guidelines may have underlying motives for these guides that may not improve your health.

In July, 2004, the nine physicians who comprise the National Cholesterol Education Program (NCEP) issued new recommendations based on the review of five clinical trials. These trials would determine if further lowering of LDL cholesterol using cholesterol lowering medications (e.g. Lipitor or Zocor) further reduced the risk of heart disease.¹  The new recommendations are as follows:

1. For very high-risk patients (individuals who've had a recent heart attack, who have the combination of heart disease and diabetes, or who have metabolic syndrome), the treatment goal is an LDL less than 70 mg/dl.
   
   
2. For high-risk patients (individuals who have coronary artery disease, vascular disease, diabetes, or 2 or more risk factors), the treatment goal is an LDL less than 100 mg/dl.
   
   
3. For moderately high risk patients (individuals who have 2 or more risk factors for heart disease), the treatment goal is an LDL less than 130 mg/dl with an option to use medication when the LDL is between 100 – 129 mg/dl.

Very few Americans have low LDL levels. According to the American Heart Association, almost 50% of men and 40% of women have LDL levels over 130 mg/dl.²  Therefore to meet these new guidelines millions more people would be required to use statin medications. Interestingly eight of the nine physicians involved with writing these recommendations were found to have financial relationships with the same pharmaceutical companies that would profit from these new guidelines.³  So in response to this, thirty-five of the nation's top scientists and physicians reviewed the research used to justify the guidelines and they disagreed with NCEP and petitioned to re-evaluate the guidelines.

This petition was a strong criticism of the NCEP recommendations with specific concerns about misinformation and a lack of supporting scientific evidence including:⁴ 

1. Statin medications reduce the risk of heart disease in women at moderately high risk who are under the age of 65.
   
   
2. Statin medications reduce the risk of heart disease in individuals above the age of 65. One of the studies reviewed, PROSPER, demonstrated a increased cancer risk in individuals over 70 that were taking statin medications.⁵ 

As I mentioned earlier, I believe focusing on lowering LDL levels alone may not be the best way to prevent heart disease. For example, one of the trials reviewed demonstrated that when the LDL was lowered from 130 to 70 mg/dl, it only reduced heart events by 15%. In fact, the director of preventative cardiology at the Women's Heart Center, New England Medical Center, found that statin medications were NOT effective in 65% of women who used this line of therapy.⁶  In other words, most individuals still had heart attacks despite aggressive lowering of LDL cholesterol with statin medication.

The American Heart Association even states that individuals with low HDL levels are at risk for heart disease regardless of their total cholesterol. In addition, individuals with high levels of total cholesterol are at lower risk if they have high levels of HDL.²  According to the Framingham Heart Study, for every 1 mg/dl increase in HDL, the risk of heart events decreased by 2 to 3%.⁶ 

Another example of the strong correlation of low HDL levels and heart disease is a study published in the Journal of American Medical Association in 1995. Here, 1377 men, and 2577 women were followed for a period of at least 4.4 years. The study showed that low HDL cholesterol was more consistently associated with an increase in death from heart disease when compared with elevated total cholesterol. This suggests that HDL levels may be more important than total cholesterol levels when assessing heart disease risk.

To take this a step further, studies analyzing blood vessel function demonstrated that lowering LDL from 130 mg/dl to less than 70 mg/dl only benefited those patients who also had a low HDL levels.⁶  The reason is that HDL cholesterol is responsible for helping remove LDL molecules from the body. Again, studies suggest that HDL cholesterol is more important than LDL cholesterol in determining heart disease risk.

Current guidelines focusing on reducing LDL certainly do not take the individuals' best interest into consideration. It is true that cholesterol lowering statin medication is effective in lowering LDL levels. The problem is that not all individuals who lower LDL levels reduce their heart disease risk. Remember, these guidelines were made by physicians with financial ties to pharmaceutical companies. Cholesterol lowering medication is big business. In 2003, Lipitor and Zocor were the top selling pharmaceutical medications in the United States with annual sales of $6.8 billion and $4.4 billion respectively.

In my practice, I've seen patients reduce heart disease risk without the use of statin medications. Instead they've done so with lifestyle change including proper nutrition, exercise and smoking cessation. We all want a "magic" pill to keep us healthy and energetic forever, however this "magic" just does not exist. Please keep this in mind anytime you watch an advertisement on TV, a friend recommends a "cure-all" or a doctor places you on a medication. Remember that risk reduction begins with lifestyle change. This change incorporates proper nutrition (including supplements), exercise, sleep, and stress management; all of which have been shown to reduce disease risk and improve quality of life without the presence of side effects.

Keith Berkowitz, MD
Medical Director
Center for Balanced Health


References
1.  ATP III Update 2004, National Cholesterol Education Program July 2004
2.  American Heart Association Statistical Fact Sheet – Risk Factors
3.  National Heart, Lung and Blood Institute website
4.  Petition to the National Institute of Health seeking an independent review panel
     to re-evaluate the National Cholesterol Education Program guidelines.
5.  Shepherd J, et al. Pravastatin in Elderly Individuals at Risk of Vascular
     Disease (PROSPER) Lancet 2003; 360: 1623-1630.
6.  "Don't overlook Importance of HDL-C in CAD Risk" Internal Medicine World Report,
     June 2004; 7
7.  Herper, Matthew. The World's Best-Selling Drugs. Forbes.com, March 16, 2004

Copyright © November 2004  Keith Berkowitz, MD and Low Carb Luxury