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Dr. Michael Smith (Host): Heart disease remains our nation’s number one killer. High cholesterol remains a significant risk factor. Welcome to The GW HealthCast. I'm Dr. Mike Smith, and today’s topic: controlling cholesterol to prevent heart disease. My guest is Dr. William Borden. Dr. Borden is an associate professor of medicine and health policy at the George Washington University, and he's also the chief quality and population health officer at the GW Medical Faculty Associates and is affiliated with The George Washington University Hospital. Dr. Borden, welcome to the show.

William Borden, MD, FACC, FAHA (Guest): Thanks Dr. Mike. Glad to be here.

Host: So, I think a lot of my listeners are probably familiar with cholesterol, and they’ve also heard of some of the other major risk factors that we talk about obesity, high blood pressure, smoking, diabetes. But when you look at that collection of risk factors, where does cholesterol really fit in? Is it one of those major risk factors? What do you think?

Dr. Borden: That’s a great question. It is really one of the main risk factors. And, importantly, it’s one of the risk factors that we can change to reduce the risk of heart disease. Clearly, as you mentioned, things like quitting smoking, losing weight, controlling blood pressure are critically important. But a study that looked at reductions and heart disease deaths over about 20 years found that probably the biggest impact in the U.S population was around reducing cholesterol levels.

Host: Very good. Let me ask you as an expert in this field Dr. Borden. We’ve spent a lot of money in research and medications and I know that there’s been a lot of education of the public about heart disease risk factors. I know for at least three decades we’ve been treating cholesterol, we’ve been encouraging people to lose weight, controlling blood pressure. Why does it still remain such a killer in this country? Are we missing something?

Dr. Borden: Well, you know there’s certainly more that we need to understand in terms of why cardiovascular disease remains such an issue. I think some of it is is that people are living longer. As people live longer, there's more time for plaque to build up in the arteries, which can lead to heart attacks and strokes. The other factor is, of course, the diet, particularly in the U.S, which remains for many people high in saturated fats and simple sugars and low in vegetables and other more nutritious foods. Then even though we’ve seen a decrease in heart attack deaths over many years. There’s a concern that that seems to be leveling off a bit. The concern is that in the U.S that’s because of increasing obesity and increasing diabetes across the country.

Host: Right, yeah. I think you're on to something there with the dietary habits there, right, of country. What do they call it? The standard American diet is SAD, S-A-D. I think it was the USDA recently showed that even though people say they’re eating healthier that most people aren’t getting enough basic vitamins and minerals from fruits and vegetables every day. So, I think you're on to something there with the dietary habits. Let’s do this, Dr. Borden, for this conversation. Let’s first talk about how we can asses our risk of heart disease with cholesterol. What kind of tests are available? Then if it is high or it’s getting close, what are the things we can do to prevent in terms of diet? Then, of course, we can talk lastly about medication. So, let’s start with what do I do? I know there’s the basic cholesterol test. Is that still the standard thing to do? Are there other advanced tests that are available? What is your take on that?

Dr. Borden: So, for the vast majority of people, it’s just the simple cholesterol test and then knowing one’s numbers. So, knowing their blood pressure, their blood sugar, their body mass index, which is a measure for diabetes. Then knowing things like one’s family history. With this information, we can plug this into a calculator which is called the atherosclerotic cardiovascular disease calculator. That tells us what someone’s risk is for a heart attack or stroke in the next 10 years. So, we can take those numbers, which are the assessment of someone’s risk, plug it into that calculator and get a number.

Then where we’re able to go with that is that there are guidelines based on research, which tell us that, for example, someone who’s risk is greater than seven and a half percent would be indicated for being on cholesterol lowering medicine. Someone who’s risk is between five and seven and half percent may be indicated, but that’s really more of a discussion between that person and their doctor.

Host: So how often should this kind of evaluation be done? How often should somebody assess their cardiovascular risk? Let’s say their healthy, they go through this-- They're in their mid-40’s, let’s say. They go through this test and everything looks fine. Is this something they should do yearly still or every three years? What do you think?

Dr. Borden: So, it depends. I think that it depends on someone’s risk. But, in general, getting a lipid panel, a cholesterol screening, about yearly makes the most sense for most people.

Host: So, let’s say I go through this and my doctor looks at all these different risk factors, looks at my cholesterol. Let’s say everything’s a little high. Maybe my risk is moderate. Let’s talk about prevention now. What are the first steps that I should do in order to get control over the situation? Let’s focus on diet first. What do you suggest?

Dr. Borden: Sure. So, diet, it’s interesting. The research on diet, it’s hard to get really good research studies in this. Some of the research that’s out there seems to point at eating less saturated and trans fats, less simple sugars. In general, I think trying to reduce those simple carbohydrates. Instead, people should really be focusing on having more vegetables, some fruits, whole grains. So, things like brown rice instead of white rice. Then lean protein. Particularly fish, but also things like turkey or chicken baked or grilled, not fried.

Host: Yeah, yeah. It sounds like when you talk about the fruits, the vegetables, the leafy greens. Good, lean protein that’s a little bit smaller. That sounds a lot like a Mediterranean based diet. Do you have any opinion on that particular type of diet?

Dr. Borden: Yeah, the Mediterranean diet is probably one of the best studied diets out there. There have been studies going back several years looking at this that basically follows that pattern. Very low in saturated fats, some low-fat dairy, whole grains, lots of fruits and vegetables. Usually cooking with olive oil. Including nuts which are high in protein to help keep people full, but then also have some healthier fats within them. So, the Mediterranean diet is a good one, and it’s also one that I recommend because it generally fits in with people’s lifestyles. It’s the sort of thing you can cook at home with your family. You can even travel and eat out and sort of stick to that sort of diet.

I do think it’s worth mentioning that some of the plant based diets and things like the Ornish diet have research to support them being very effective in reducing cardiovascular events like heart attacks, and also actually causing plaque to decrease in the arteries. Those tend to be a little bit more challenging to follow as people are going about their daily lives. That being said, for the right person who’s highly motivated, I think those sorts of diets can be really effective.

Host: Right. If I'm not mistaken, I thought I saw some research before demonstrating that about 80% plant based, 20% protein seems to be a good ratio for reducing heart disease risk. A lot of people hear this, Dr. Borden, and they’ve heard about the Mediterranean diet. If I start doing that, let’s say, or let’s say you suggest that to a person at moderate risk, what kind of lowering of cholesterol on those diets can they expect? I get that that might be hard to answer because everybody’s a little different but are there any studies that show us some numbers, some reduction of cholesterol.

Dr. Borden: Yeah. There are some studies that look at that. In general, it depends on the person and how much of their cholesterol is being driven by their genetics, what they inherited. Certainly, if you’ve got someone who’s eaten cheeseburgers everyday for lunch, if they change their diet, they're going to see a substantial decrease in their LDL—that sort of bad cholesterol. The other area where we can see improvements is in another form of the bad cholesterol calls triglycerides. Triglycerides are very responsive to cutting back on carbohydrates, particularly simple carbohydrates. Then cutting back on things like alcohol. So those can impact the triglycerides quite a bit. The LDL bad cholesterol, a little bit more difficult to move with diet changes unless at baseline someone is really eating a very high saturated fat diet.

Host: Right, right. To be honest too, if somebody’s following that kind of diet and they lose some weight, maybe they feel better, they're becoming more active, maybe using less salt. So, triglycerides are down a little bit, sugar’s down a little bit. Even if the LDL doesn’t budge too much, overall their picture is improving right?

Dr. Borden: Absolutely. There are studies, and you mentioned some of the studies that look at the Mediterranean diet and showing reductions in cardiovascular events. There’s other benefits to that sort of approach in losing weight, and that reduces the risk for diabetes, can bring people who are in pre-diabetes out of pre-diabetes back to normal. It can help lower blood pressure. So, there are a lot of benefits in addition to what benefits we might see in the actual cholesterol numbers.

Host: Right. So now walk us through the process. If somebody is working on their diet but their LDL is too high, and the decision is made that medication has to be started. Walk us through a little bit of that process. Which medications, how they're going to be followed, and what the goals are once you’re on medication.

Dr. Borden: Absolutely. I always talk with my patients first and foremost about diet, as we've just discussed, as well as exercise, which is a key component. For that I recommend 150 minutes a week of moderate intensely aerobic exercise, which can be a brisk walk. Doing that for 30 minutes five times a week or 50 minutes three times a week. Obviously smoking cessation and then stress reduction I think is an important part of the lifestyle changes that we can all make. Sometimes easier said that done, but important for all of us.

For many people, when you calculate that risk, it puts them in the category where the evidence based guidelines would say someone should start on a cholesterol lowering medicine. The cholesterol lowering medicines that far and away have the most support behind them are what are called statins. So, these are things like atorvastatin or simvastatin. The decision to start this is really always a discussion with the patient and their physician. So, having it talk about what are the potential benefits of starting on a statin, what are the risks, and what are those patient’s preferences, and in consideration of other medications and other conditions that that individual might have. Then if the decision is made to start on a statin is to follow up and see the response to the statin and continuing along with that in addition to the lifestyle changes.

The other comment I would just make is that I think that there’s a lot out there about statins and the internet and complications from statins. The reality is that they are one of the best studied medications that we have, and many large research studies. We understand them and their risks pretty well. There are some rarer complications, but the main thing that people can get are some muscle aches, which really only happens in about 1 in 10 to 1 in 20 people. Generally, it’s mild and it can be managed. It’s important to understand the information about statins and have that conversation with your physician to understand that because there’s tremendous benefits to the statins. I think sometimes people might get scared away from statins when they might actually benefit from them.

Host: Right, right. I think that’s an important point. As physicians, we’re always looking at the benefit to risk ratio in a sense, right? For most people, the benefit of the statin far outweighs any of those risks. The benefit to reduction in cardiovascular risk far outweighs any of those side effects or more people, and I think you would agree with that, correct?

Dr. Borden: Absolutely. Yep.

Host: So, what a great conversation about managing cholesterol Dr. Borden. How about if we do this. Let’s end with having you just kind of summarize what would you like the audience to know about cholesterol and the prevention of heart disease?

Dr. Borden: I think the key takeaway is one is to understand your risk by understanding your cholesterol numbers, your blood pressure, an assessment of your body weight, whether you smoke, understand your family history. Because that’s the first step is, we all have to know what our risk is for cardiovascular disease. Number two is working on those lifestyle modifications that we talked about with diet, exercise, smoking cessation, stress reduction. Number three is that because cholesterol plays such a role in the risk for heart attacks and strokes is having that conversation with your doctor about whether—based on your risk—it would make sense for you to be on a statin to reduce that risk. Then working with your physician on an ongoing basis to try and maintain those lifestyle changes and continuing to monitor your progress.

Host:  Dr. Borden, that was an excellent summary. I want to thank you for the work that you're doing at George Washington University, and also thank you for coming on the show today. You're listening to the GW Healthcast. Please visit GWDocs.com to get connected with Dr. Borden or another provider, or call 1-888-4GW-DOCS to schedule an in-person or virtual appointment.