Transcription:
High Cholesterol: Is It My Lifestyle Or My Genes

Melanie Cole (Host):  Welcome to Northwestern Medicine Pod Talk. I'm Melanie Cole, and I invite you to listen as we discuss Northwestern Medicine Central DuPage Hospital Lipid Clinic. High cholesterol, is it in my lifestyle or my genes? Joining me is Dr. Robert Nierzwicki. He's a Cardiologist at Northwestern Medicine Central DuPage and Delnor Hospitals.

Dr. Nierzwicki, it's a pleasure to have you join us. Thank you so much. I'd like you to give the listeners a little working definition. Not yet everybody knows what cholesterol really is. If it's something we only get externally from our diet. If it's something that our body makes, if it's good or it's bad, or both. Tell us a little bit about cholesterol and how important it is to our body's functions.

Robert Nierzwicki, MD (Guest): Sure. Well, thanks a lot for having me on the podcast. So, cholesterol ends up in the bloodstream in a combination of ways. Some people it's more so through what they take in through their diet and what is absorbed through their intestines. And there's also cholesterol that is produced in the liver. So, even if you don't consume any cholesterol in your diet, you can still have high cholesterol levels by your body's own production. And different people have a different combination of what is more prevalent. But whatever ends up in the bloodstream, that is what is important and what we focus on as far as risk factors and treatment. So, there's a lot of things that influence it; diet, exercise, weight, but just your body's own natural metabolism determines what your cholesterol levels are.

Host: Can you tell us, we've heard the terms good and bad cholesterol. What does that mean? And why are they good or bad?

Dr. Nierzwicki: Sure. In general, there's different subtypes of cholesterol as it circulates through the bloodstream. There is the what we consider the good cholesterol, which is HDL and in general, that removes cholesterol from the bloodstream so that it doesn't end up in your lining of your blood vessels. And there's what we also called the bad cholesterol, which is LDL cholesterol, which circulates and deposits cholesterol in different organs throughout the body, including in blood vessels. So, that's the differentiation that we usually make between those different subtypes.

Host: Dr. Nierzwicki, when we get our blood tests and we're looking at our results, there's a lot of different lipid numbers. There's a whole lipid profile, triglyceride and then HDLs and LDLs and all of these things. Can you tell us what those numbers mean, where you want our cholesterol levels to be and why it's important that we know these numbers?

Dr. Nierzwicki: Sure. So, in general, there is four main categories that will show up on your blood test. There'll be the total cholesterol, which takes into account triglycerides, HDL, and LDL. And then it's further broken up into several subtypes. There's the HDL, like I mentioned, the good cholesterol, the LDL, the bad cholesterol, and then the triglycerides, which are the building blocks of fat molecules in the body. And in general, we want to get your LDL numbers for most people, the goal would be around less than a hundred, but for people that are higher risk or people that have had heart disease, you want to get that LDL less than 70 and sometimes even lower than that. For HDL, there's not too much we've found as far as medication wise, that can raise that.

There can be things in the diet and lifestyle, such as exercise that may raise the HDL a little bit and that can help improve your risk for heart disease. But from a medication standpoint, not much affects that. But your body's overall metabolism determines usually what your HDL level is. Now triglycerides compared to the other components can be much more dependent on what you've had from a diet standpoint, especially in the last 48 hours.

So, if you weren't fasting for a blood test, and your triglycerides are elevated and that may be due to fat molecules from recent meals that you've eaten. But in general, we try to keep that triglyceride levels less than 150, and there are several things that we can do from diet, exercise, weight loss, if you're diabetic, management of blood sugar is important for management of triglycerides as well, that can help lower that.

Now in general, there's been a strong correlation with elevated LDL levels and the risk of heart disease that can lead to heart attack, angina, it can also be correlated with stroke as well. That's why it's important to get those LDL levels in an acceptable level.

Host: Well, thank you for that, Dr. Nierzwicki. So, please tell us about the Northwestern Medicine Central DuPage Hospital Lipid Clinic. Tell us what it's like there, what you do for patients and while you're telling us that, how does genetics impact lipid disorders? Tell us all how this all goes together with what you do.

Dr. Nierzwicki: Sure. So, there's in most people, a combination of lifestyle factors and also genetics that play a role in what your cholesterol levels are going to be. Now, some people have a heavy genetic component and some people have one specific gene that significantly affects their cholesterol levels, specifically their LDL. Those are people that have a disorder called familial hypercholesterolemia and that can lead to very high LDLs. And those people are at significantly elevated risk of heart disease over their lifetime, compared to the general population. The Lipid Clinic is trying to find these patients and make sure they're getting appropriate counseling, genetic testing, if that's appropriate, so that they can know what mutation they may have in their genes. And so that, that can be passed on to other family members. And it's also important to make sure that they're appropriately treated so that their risk of having a heart attack can be significantly reduced with the proper medications. Now there's also a class of people that have significantly lifestyle effected cholesterol levels, and those people may not have some of the specific genetic things that we're looking at in familial hypercholesterolemia, but they can still benefit from significant education on what are healthy lifestyles and still the appropriate management with other treatments, medications, and the list of medications for managing LDL has grown significantly over the last five years to allow almost everyone to get in an acceptable LDL level.

Host: It's really such an important topic for people to hear. So, as you're telling us about the lipid clinic, and you've mentioned diet, lifestyle, exercise; what kind of diet can help to lower those cholesterol levels? When you're giving your best advice, Doctor to people every single day, what are you telling them about the recommended amount of exercise to actually affect cholesterol levels and what type of foods we're talking about that can help? Because we hear about certain foods that have the good cholesterol that can help bring down the bad cholesterol, but it can be very confusing for listeners.

Dr. Nierzwicki: So, in general, starting with diets, you know, I tell all my patients the more you can add whole plant foods to your diet, so whether that's fruits, vegetables, especially leafy green vegetables, nuts, seeds, whole grains foods that are just naturally high in fiber; that's going to have the most significant effect as far as lowering cholesterol, specifically the LDL. Things that I tell my patients to try to avoid are mainly trans fat, which is a lot of processed food. Now, fortunately, most of that trans fat has been removed from food products because of regulations. However, that can still be present, especially in meats.

Things also to avoid are foods that are high in saturated fat that can lead to higher levels of LDL. And then specifically foods that are high in cholesterol because your body already produces its own cholesterol. It doesn't really need any additive cholesterol in the diet. So, that would also be something that I tell my patients to avoid, especially if they have high LDL levels to begin with.

Now, when it comes to exercise, I would recommend moderate to high intensity exercise, at least five days a week for a duration of 30 minutes or more so 150 minutes to work up to maybe even 200 minutes per week, as far as exercise. Now, not everyone starts at a level where that can be achievable within a short period of time. So, that's the goal, but if you're starting with no exercise, I just tell people, start with something that is 10 minutes a day of an activity that gets your heart rate up. And then every week you just slowly build up on that activity until you reach those goal levels. Now, some people may be able to do the highest intensity exercise they may be able to do would be walking. And if that's the most they can do, then that's fine. But there's some people that can push themselves beyond that point. And that would be advised.

Host: Very comprehensive, excellent information. So, now let's briefly touch on medications. We hear a lot about statins. We hear about the side effects. People may be hesitant to try cholesterol medications, and yet they can help with heart disease and cholesterol and plaque buildup, and that sort of thing. Definitely want to try the lifestyle and dietary recommendations you just gave first. But when it comes to medication, why are people so afraid? Just kind of tell us a little bit about the medications and why you prescribe them.

Dr. Nierzwicki: Sure. So, you're right, first-line therapy for everyone for cholesterol management is always those lifestyle factors. There's still a significant proportion of patients who can't achieve acceptable levels with those lifestyle factors. And then we would go to medications. Now, the first line medications is the class of medications, the statins, and those have been extensively studied since the 1990s and probably the most studied class of medication in the history of the world.

Now those medications have been looked at in numerous what we considered the gold standard randomized controlled trials to look at one, their effectiveness and also their safety. Now there has been some issues with side effects with some of the statins, which tend to be dose-related and can vary from one statin to the next, depending on the person.

And in randomized control trials, one to maybe 5% of patients have shown some issues with muscle weakness or muscle pains. Now, even if that's the case, they may tolerate one medication over another, or they may be able to tolerate a lower dose compared to a higher dose, instead of having to completely rule out that class of the medications.

So, multiple trials have shown that they can significantly decrease the risk of heart attack and stroke and death from cardiovascular events, with those medications. Now there's several newer medications out and they have had similar effects. However, the statins because they're generic, they are cheap. They have been the most widely studied and have significant data. That is why they are the first line treatments. Now patients sometimes cannot achieve acceptable cholesterol levels with just the statin medication, or they may be completely intolerant of any statin medications which can happen even though that's a small percentage of patients.

And in that case, there are several second line medications that some of them are generic. Some of them are newer medications that are still in their study phase but plenty of options available nowadays.

Host: Well, there certainly are. And as we wrap up, please reiterate the importance of knowing our cholesterol numbers, dietary, and lifestyle behaviors, and kind of summarize for us the Northwestern Medicine Central DuPage Hospital Lipid Clinic, and what you're doing there that's exciting for patients.

Dr. Nierzwicki: So, as far as knowing your cholesterol numbers, for most people, this may be one of the easiest modifiable risk factors for heart disease. And that can be as simple as some lifestyle changes or a once a day generic medication that can significantly lower your risks. So, that's why it's important to know that. Now specifically, as far as those lifestyle factors, a plant-based diet, avoiding diets that are high in processed food and saturated fat are going to have the most effect and trying to achieve an exercise goal of 150 to 200 minutes a week is also going to help lower that LDL.

And then a certain percentage of patients may have significant genetic effects to their cholesterol. And the Northwestern Lipid Clinic at Central DuPage Hospital is looking to find those patients, address what their risk is, assess their genetics and appropriately treat those patients so that can significantly lower their risk and have a long, healthy lifestyle.

Host: What a great informative episode this was. Dr. Nierzwicki thank you so much for joining us. For more information, please call 312-NMHEART, or you can visit heart.nm.org for more information, and to get connected with one of our providers That concludes this episode of Northwestern Medicine Pod Talk. If you found this podcast informative, please share on your social channels. That way we're learning from the experts at Northwestern Medicine together. I'm Melanie Cole.