All Posts tagged cholesterol

Maintain Your Brain

            Seventy year old Mrs. Lansing drew a complete blank as I asked her if she could recall any of the five words I’d given her to remember some 4-5 minutes ago as part of her mental status exam.  Inwardly I always wince at those moments.  It feels like I’m unintentionally bullying a harassed person into looking the fearful specter of their approaching dementia directly in the eye.  Her husband quickly came to her rescue with a small white lie, “That’s alright darlin’, I don’t remember any of them either,” and we all smiled with relief.

Dementia is the common term for a set of symptoms including memory loss, mood changes, and difficulty with communication and reasoning.  Modern medicine is trying to replace the term with “major and minor neurocognitive disorder”.  Yah, for now let’s stick with the term everyone knows, dementia.  There are several types of dementia, with the most common two being Alzheimer’s disease (AD) and vascular dementia (due to atherosclerosis [plaque] on the blood vessels supplying the brain) coming in a close second.

AD currently affects about 5 million Americans.  There are a handful of approved prescription medications to treat AD.  They delay (but do not stop) the progression of the disease by about 6 to 12 months.  This is useful, but far from a cure.  Likewise various supplements and vitamin treatments have come and gone over the years.  When subjected to careful scrutiny the results have generally been disappointing.  The likelihood of AD dramatically increases with age, roughly doubling in likelihood every 5 years after age 65.  If one lives to 85 years old the likelihood of having AD is almost 50%.

So can anything be done to prevent it?  Of course certain risk factors cannot be altered, such as age, family history and genetics.  But at the same time, there is a growing body of research showing that certain lifestyle choices have a substantial impact on whether AD or vascular dementia will indeed show up in your life.  Certain treatable maladies contribute to a significant increase in dementia.  For example, dementia is:

  • 41% higher in smokers
  • 39 % higher in people with high blood pressure
  • 22% higher among whites who are obese
  • 77% higher in diabetics

So obviously there is room for better lifestyle and aggressive treatment of these

conditions to help delay or prevent the onset of dementia.  A recent article predicted that substantial improvement in lifestyle factors could reduce the risk for AD (and perhaps even more so vascular dementia) by 50%.

What lifestyle factors can substantially impact the likelihood and/or timing of you or me getting dementia?

  • Being a regular exerciser could reduce AD by 21%. A recent study showed 5% greater brain mass retention in active folks vs. inactive.  Five percent may not sound like a lot, but when it comes to the brain, it is substantial.  A reasonable goal in terms of time and activity would be a 30 minute brisk (3-4 miles per hour) walk or the equivalent 5 days per week.
  • Quit smoking
  • Avoid excess alcohol. Anything beyond one drink a day in females or two daily in males is associated with increased risk of dementia.
  • Stay socially connected and mentally active.
  • A heart-healthy diet rich in nuts, seeds, whole fruits and vegetables, olive oil, fish and other low fat meats, and low in sugars and simple carbohydrates is beneficial in reducing vascular dementia.
  • Finally, if you have diabetes, cholesterol issues, obesity, or high blood pressure, treating these well can impact the incidence of dementia.

In the end, there is no way to guarantee that you will avoid the scourge of dementia.  At the same time, we want to avoid the fatalism that assumes that nothing we do will impact its likelihood or timing.  Dementia is a grim enemy.  While more weapons against it are sought, it’s worth using every one that is available to delay or prevent it.

Andrew Smith, MD is board-certified in Family Medicine and practices at 1503 East Lamar Alexander Parkway, Maryville.  Contact him at 982-0835


Cholesterol Myths

“So, my cholesterol’s running high?  It’s probably all those eggs I’m eating.  Give me a couple of months and I can fix that with my diet.  I don’t want a heart attack… but I also don’t want to be on one of those statin drugs.  Who wants something that saves your heart but then wrecks your liver?

Those are the kinds of statements I hear day in and day out in my practice.  They express several of the myths that are rampant about cholesterol.  In fact cholesterol has recently been in the news because the government’s Dietary Guidelines Advisory Committee is reportedly going to remove their longstanding recommendation to restrict cholesterol in the diet.

The wheels of science often grind very slowly and sometimes get stuck in a misguided rut for long stretches.  One of those ruts has been the idea that cholesterol in the diet, such as is contained in the yolk of an egg, needs to be carefully limited in order to protect one’s heart health.  It seemed to make sense since cholesterol is found in some of the plaque that blocks arteries and leads to heart attack and stroke.  But over the years the evidence for the evils of dietary cholesterol has simply not shown up.  In fact, as heretical as this may at first sound, a lot of folks with the very common pre-diabetic metabolic syndrome would do better having an egg and a little cheese for breakfast rather than a bowl of oatmeal.

Even after decades of study, we are far from figuring out all that there is to know about cholesterol and cardiovascular health.  But if we can’t give all the answers, let’s at least explode a few myths.  Besides the one noted above about the assumed dangers of dietary cholesterol, here are three more:

  • Myth #1: High cholesterol is mostly due to a bad diet and can be readily fixed by adjusting your diet.  Reality: For most people cholesterol is about 80% genetics and 20% lifestyle.  So it can certainly be improved with a healthy lifestyle, but there is a large part of it over which we have little control.  It’s still good to work at the 20%, but it’s not a simple fix.
  • Myth #2: Anyone with high cholesterol is at risk and would probably benefit from a statin drug.  Reality: These cholesterol-lowering medicines do work very well to lower cholesterol.  However, the main place that they have shown a reduction in events (such as heart attacks) is in folks with known heart disease, or (less so) in those with very high risk factors for heart disease.  Some folks with high cholesterol are actually at very low risk for heart disease and stroke.  That’s why in trying to better answer whether one of our high cholesterol patients should consider a statin, we employ tests such as the coronary calcium scores and/or a specialized arterial ultrasound called a carotid intimal medial thickness test.  These are non-invasive and affordable tests which help us sort our high cholesterol patients into those who are clearly plaque-formers and those who don’t seem to be.  We then recommend consideration of a statin, as well as other aggressive preventive measures only for the plaque-formers.
  • Myth #3: Cholesterol-lowering statin drugs are quite dangerous and can wreck your liver. Reality: Although, as noted above, they are certainly not needed by everyone with high cholesterol, they have been quite thoroughly tested and their side-effects are well-known and manageable.  For example, there is no statistical increase in liver failure among those on statin drugs vs. those not taking a statin.  However they do bump blood sugar up mildly and probably around 15% of folks get muscle aches that cause us to switch brands or take them off statins entirely.  So statins are neither the big answer nor the big villain; they’re just another tool.

We could go on, but you get the idea. As with most things, reality is a little more complicated than the myths.  It is often said that half of what we put forth as medical truth is false… and the trouble is we don’t know which half is which.  It should keep us humble, but it shouldn’t make us despair.  After all, for about 1900 years after Christ, the average life-span was stuck at about 38 years (partly because of the high number of infant and childhood deaths) whereas we’re at more than double that now.  Over time, if we follow the evidence and resist impatiently grabbing the newest too-good-to-be-true fix-all promises, we do arrive at some helpful realities.  In cholesterol management as with the rest of life, hang in there and keep holding out for the true and the good.


How’s Your Heart?

Maybe it’s the countless images of hearts everywhere I turn during this Valentine’s Day season, but it seems we should talk a little about protecting our hearts. If we were living in the U.S. in 1900, the top three causes of death would all be infectious diseases: flu and pneumonia (lumped together), tuberculosis, and gastrointestinal infections. And I probably wouldn’t be writing this article since the average life expectancy for men was 46 years old.

With the introduction of vaccinations, antibiotics, and overall better nutrition and sanitation, these infectious causes have retreated substantially. In their place, and reigning as the number one cause of death for many decades, is heart disease. It currently causes almost three out of every ten deaths.

One of the major forms of heart disease is coronary artery disease (CAD), in which the arteries supplying the muscle of the heart become blocked. When that happens, the oxygen- starved muscle generally hurts, causing a kind of chest pain we call angina. If the coronary artery is completely blocked, the part of the heart muscle it supplies dies. This is what’s going on in a heart attack (medically termed a myocardial [heart muscle] infarction [tissue death due to blocked blood supply]).

The stuff that blocks arteries is called plaque. Risk factors for plaque, and thus for heart attacks (as well as the strokes which happen by a similar process) are:

  • Smoking
  • High blood pressure
  • High cholesterol
  • Diabetes
  • Overweight
  • Physical inactivity
  • Having a family history of early heart disease
  • Increasing age

As you can see, several of these risk factors are manageable. One of the problems with prevention is that CAD is often a silent process until critical blockage occurs. Of course knowing the risk factors and working to combat lifestyle issues such as lack of exercise, overweight, smoking, and even diabetes is huge when it comes to prevention. In addition rather simple tests such as coronary calcium scores (a fairly inexpensive low dose cat scan picture of the arteries around the heart) can give further information about plaque on the coronary arteries. It’s not a perfect test, but it correlates pretty well with risk for future heart attacks or angina.

So as Valentine’s Day 2014 recedes into the past, as you ponder the status of your emotional heart, give your physical heart a little thought as well. If you have some reversible risk factors, go after them this year. And if you really don’t know the status of your cholesterol, blood sugar, or blood pressure, get them checked out. Also, see if your doctor recommends a coronary calcium score or other testing to further assess the status of your heart. All-in-all, it’s better to be aggressive with prevention now than with stents and bypasses later.

Andrew Smith, MD is board-certified in Family Medicine and practices at 1503 East Lamar Alexander Parkway, Maryville. Contact him at 982-0835



The Syndrome That’s Sweeping the Nation

The Syndrome That’s Sweeping the Nation

The Syndrome That’s Sweeping the Nation

One of the most common and damaging diagnoses I see day in and day out is one whose name many of my readers have heard little about. It is a syndrome that is epidemic in the U.S. with a staggering 1/3 of adults meeting its diagnostic criteria. It parallels the rapid increase in overweight and obesity in the U.S. (with 2/3 of adults now falling in these categories). With obesity occurring in children and adolescents at three times the rate that was present in the 1960’s, this syndrome is also becoming more prevalent in these younger ages as well.

One “catches” the syndrome by lack of exercise, having a poor diet (especially one high in simple carbohydrates – sugars and starches), and putting on belly fat. Hours logged in front of the TV, computer, or video games sipping sweet drinks or beer and munching on carbs puts us on the fast lane to developing this malady. The condition we’re talking about is called metabolic syndrome.

Metabolic syndrome arises from insulin resistance in the body and increased fat deposition. Over time, as we fall into a lifestyle that has little regular exercise and lots of starchy or sugary meals, the insulin produced by our pancreas has less and less effect in the body. Eventually our blood sugar starts to rise, despite there being plenty of insulin circulating.

This situation has numerous negative effects on the body. That’s why metabolic syndrome is a risk factor for heart disease, stroke, diabetes, fatty liver, sleep apnea, and several cancers, including colon, kidney and breast. There is even some evidence that it accelerates cognitive (brain function) aging and deterioration.

How is this syndrome diagnosed – how do I know if I have it? The diagnosis is based on having at least 3 of the following 5 characteristics:

  • Fasting glucose ≥100 mg/dL (or on meds for diabetes or high blood sugar)
  • Blood pressure ≥130/85 mm Hg (or on meds for high blood pressure)
  • Triglycerides ≥150 mg/dL (or on meds for high triglycerides)
  • HDL-C (“good cholesterol”) < 40 mg/dL in men or < 50 mg/dL in women (or on meds)
  • Waist circumference ≥40 inches in men or ≥35 inches in women; if Asian American, ≥ 35 inches in men or ≥ 32 inches in women

Yes, metabolic syndrome can be treated with numerous medications that help reduce blood sugar, lower triglycerides and control high blood pressure. But that’s not the first way to go about this. The real core of treatment involves turning around the habits that got us there in the first place. A healthy low carb diet and a 30 minute brisk (3 to 4 mile per hour pace) walk 5-6 times per week (or the equivalent on a stationary bike, elliptical, swimming, etc.) producing a slow weight loss can typically cure, or greatly improve this syndrome. Of course the challenge is actually doing this and sticking with it. Finding a group or partner to do it with is hugely helpful here. And the health rewards are enormous as you begin to feel better, get your energy back, and minimize the long list of complications of metabolic syndrome.

Beyond the daunting personal impact of metabolic syndrome is the fact that if we try to treat it only with medicines, or if we just wait for all of its complications to show up and then treat them, it will absolutely overwhelm the health system in our country. So if you caught this syndrome, or see yourself heading that way, find a partner and start working on the self-cure. You may or may not need a little help from a medicine, but your efforts are the cornerstone of the cure. So don’t be trendy on this one; make the effort to help this popular syndrome pass you by.

Andrew Smith, MD is board-certified in Family Medicine and practices at 1503 East Lamar Alexander Parkway, Maryville. Contact him at 982-0835