Joey Wahler (Host): The CDC says it's too high for about one in 10 Americans. So, we're discussing controlling cholesterol. Our guest is Eric Shoup. He's a physician assistant and clinical lipid specialist.

This is Flourish, a podcast from Prisma Health. Thanks so much for joining us. I'm Joey Wahler. Hi there, Eric. Welcome.

Eric Shoup: Thank you, Joey. Appreciate it. Glad to be here with you.

Host: Yeah, appreciate the time. Great to have you aboard. So first, we hear about it a lot, of course. But for those that don't know specifically, what exactly is cholesterol?

Eric Shoup: Yeah. So, cholesterol is something that we all need, right? We need it to make the cell membrane formation. We need it for hormone production for both men and women. So, it's a necessity and our body creates enough of it, for the most part, to take care of those things. So when people say, "Oh, well, cholesterol's bad for you," well, too much cholesterol is bad for us, but we need some in order for the daily function of our bodies.

Host: Interesting, because I think you hit on it there. I get the feeling many people are under the misconception that all cholesterol is bad. So, that being said, why is high cholesterol a problem for us?

Eric Shoup: Yeah. So, high cholesterol, when we have too much of it, the body is looking for places to put it. And a very tempting place for that is to be out in our arteries. So, our arteries in our neck, in our heart, in our limbs, like our legs. And so, it slowly deposits it there, because there's no other place for it to go.

And over time, right, unfortunately, the atherosclerotic process, the process of laying down plaque in our arteries, it's not harmful until the end—until the end where we have symptoms like a stroke or a heart attack or a cold limb, right? So, this is a process that's slowly ongoing in many of us, and a lot of us don't even know that it's getting to a point where it's a problem.

Host: Right. So, it just kind of sneaks up on many people. So, what causes high cholesterol and can it be hereditary?

Eric Shoup: So, to keep it simple, I mean, the lifestyle and the heredity are probably equally important. There's certain percentages and some studies that are out there. But there are some people, it's frustrating for them because they are very strict with their diet. I joke with some of my patients and I say, you know, you unfortunately could eat grass and drink water and run a marathon every other weekend and, unfortunately, your predisposition to have high cholesterol just overcomes your lifestyle ability to modify it.

But other people, they respond fairly well, especially people who are overweight or they're diabetic, they have a lot more room to make changes. They can make some significant changes with their numbers in comparison to the other group that I just mentioned. So, it's all trial and error. So, I usually have people come in, and they'll choose lifestyle modification for about three to six months and work very diligently. We will see where they're at and decide where we need to go from there. But the first step is usually always lifestyle, unless they have a significant family history or they already have cardiovascular disease of some sort.

Host: Gotcha. So, that being said, what's a "normal cholesterol range" for most people? And there's also such a thing as good and bad cholesterol, right? So, what's the difference between those two?

Eric Shoup: So, your basic lipid panel, you'll get a fair amount of information. You'll get a total cholesterol, you'll get it broken down into good and bad. And you'll get a triglyceride level too, because that's part of the process as well. So typically, for most people, it's what we call primary prevention, so you go to your provider and you don't have any history of any cardiovascular issue, your total cholesterol, roughly about 180 or less is a good place to be. Your bad cholesterol somewhere around 130, maybe below a hundred. There are risk calculators that are out there that you can see online. There's a Framingham risk calculator. There's a Reynolds risk calculator.

But one that's probably used more than the rest is called a pooled cohort risk calculator. So, this is something you can pull up online. It's got your age, your sex, your race, what your total cholesterol is, what your HDL cholesterol is, and are you treated for hypertension? Do you smoke? And are you diabetic? So, you put all that information in and it'll calculate a risk score. And that will help you decide what in particular your cholesterol value should be. Are you low risk? Are you borderline risk? Are you intermediate risk or are you high risk? And as you figure those out, then that will specify kind of what your LDL cholesterol value should be.

Host: Can good cholesterol balance out the bad?

Eric Shoup: Yeah. So, we hear that all the time, right? I have a lot of patients who come in and they say, "My HDL is so high that people tell me that I don't have to worry about my bad cholesterol." And I go, "Well, I have lots of people who come to me with pretty good HDL values in the 60s and 70s, yet they still have trouble and they have to go to the cath lab and have some procedures done."

So, having a high good cholesterol is helpful, but it doesn't completely negate having a high bad cholesterol. So, the bottom line is you would like a good mix of both. Make sure you try to do things to help raise your good cholesterol, like, good weight management, good lifestyle, exercise on a regular basis. Those are very helpful. And then, with the other side of the coin is, you know, good, low saturated fat intake, low cholesterol intake, things of that nature. So if you balance both, then you'll get the best of both worlds.

Host: And so, at what point should we get our cholesterol checked? That, of course, presuming it's not been checked in a while, which of course it should be regularly.

Eric Shoup: Yeah. So initially, what'll happen is, you know, your pediatrician usually is going to check it at around age 10. Now, sometimes they'll check it a little bit earlier, especially if there's a strong family history of cardiovascular issues. They'll maybe check it at age two to kind of get a jump on it, but age 10 and then at age 20. And then, typically every five years after that, unless you need to be treated. And then, once you go down that treatment paradigm, it all depends, you know, is it lifestyle check in three to six months. If you're starting to have to consider medications, then you might want to have those follow-up between one and three months after change in medical therapy.

Host: Okay. Now, in order to lower that bad cholesterol and raise the good, what are some of the foods that are best for lowering high cholesterol, and which ones should we stay away from?

Eric Shoup: The best thing to do is to eliminate processed foods, right? So if you look at the label and you see anything that reads hydrogenated, just kind of keep on walking past that. Whole foods is the best thing to do. I mean, back when my parents were kids, you know, everything was pulled out of the garden. It wasn't freeze dried or frozen or warmed up in a microwave or boiled away in a pot of hot water. So, whole foods, Mediterranean diet, that works very well. So, those are the things to kind of go for. So, good balance of fruits, vegetables, lean meats, stay away from fried foods, anything that's fatty. Those tend to be problematic.

Host: Eggs, as you well know, are always a big focal point when talking about cholesterol. Some are probably under the impression they should be avoiding eggs altogether. Is it that or is it just a matter of moderation?

Eric Shoup: Yeah. I would agree with the moderation part with that, Joey. The protein component, the egg white, that's very good. And the cholesterol content of it, it's not like you want to be bringing in eggs on a daily basis, but it is a good nutritional source. And so, it's just moderation with that. Your typical egg has anywhere between 150 to 250 milligrams of cholesterol in it. So, just be careful, right? You don't want to be having an omelet every day.

But really, the culprit above and beyond cholesterol is saturated fat. That is really the culprit that leads to a lot of problems. So, refined white carbohydrate, saturated fat, those are things that we need to be really careful of, right? You know, white bread, white pasta, all of those things, they tend to turn into sugar very readily. And sugar causes blood sugar to go up, that causes your triglyceride levels to go up, that causes changes with your particle distribution, how we carry our cholesterol in our bloodstream, makes it more harmful. And if you really have a lot of blood sugar issues, your cholesterol can become—a fancy term is glycosylated. That means your cholesterol can be associated with sugar, and it makes it more harmful to your arterial wall.

Host: And of course, it's always the things that taste best, that have the most cholesterol, right?

Eric Shoup: Well, that's what we're brought up with. But if we grow up on whole and healthy food, that tastes pretty good as well. But I agree. You know, I grew up in the 1970s as I'm dating myself as a child, the big thing was little Debbie cakes, right? Oh man. That's nothing but carbohydrate and sugar, so yeah...

Host: Absolutely. The oatmeal ones with the vanilla cream inside.

Eric Shoup: That too. That's exactly right.

Host: I hear you. Couple of other things, when we talk about lifestyle changes, for the sake of ideal cholesterol levels, in terms of exercise, for those that are daunted by the mere thought of exercising, being active, either because they've never been or they haven't been in a while, what are a couple of very basic, simple things that most anyone is capable of doing as a starting point?

Eric Shoup: The first thing is move. Do something and do something that you like, right? People go and they say, "Well, I have to join a gym, and then they make me do stair climbing, they make me do the treadmill." Pick something that you enjoy. Now, I tell my patients that if you depend on Mother Nature for your exercise program, it will be a hundred percent failure, okay? It's going to get too cold, too wet, too hot, too humid, too whatever. So, just make sure you have options.

So, exercise, just a regular walking program is good. It's also good to add something that has some resistance activity and that doesn't mean you have to go to the gym and pump iron. You can get a set of dumbbells at home. You can get bands that they use a lot of times for physical therapy. Because you want to make sure—because a good healthy exercise program is aerobic, is for flexibility, and for strength. Those are all things. It's great if you can run like a gazelle, but if you can't do a pull up, that's a problem. And if you can't reach down and touch your toes, that's a problem too. So, it's a balance of everything.

Host: You know, that well-rounded point you make is a very good one, because many people, that kind of escapes them. Also in terms of medication, at what point should one be thinking about taking medication for cholesterol? And is it safe to say that it's better to rely on the lifestyle changes first if those can be achieved?

Eric Shoup: When I have patients who come to me for primary prevention, so before they have any issues, unfortunately like a heart attack or a bypass surgery or a stent placed, I always try to get them to work diligently with their lifestyle for a good three to six months—so, you have time—and then see where they land.

Then, you kind of put them into, "Okay, what's your family history?" "Okay, what's that pooled cohort risk calculator?" "Do you have like a predisposition for awful cholesterol?" There's something called familial hyperlipidemia, that's a fancy term saying if you have that, the likelihood that lifestyle alone is probably not going to get you to goal. An easy way to calculate that is, if your bad cholesterol, your LDL, is 190 or greater, you have it, and then move from there.

The other class of patient is the diabetic. So, diabetics, they're treated almost like they have cardiovascular disease, because of what we had talked about with the glycosylation of the cholesterol and more harmful. So, that patient population, you tend to move to treatment earlier. But other than those, FH patients, diabetics, and people who already have established disease. Otherwise, it's, "Okay. Let's see how you can do lifestyle-wise, and then we'll reassess."

Host: And in summary here, Eric, you've done such a great job covering some of these details. Overall, for those struggling with high cholesterol that are joining us and they want to know what's the main takeaway here, what would you say?

Eric Shoup: I would say don't despair. When I first started in medicine, we had over-the-counter niacin and questran, which is what you mixed in a glass of water like metamucil and you drank it. If we could get your LDL cholesterol down by about 20 to 25, that was a major accomplishment. We have medicines now across the board that I can take people and I have taken people's bad cholesterol values of 600 or 700 and be able to normalize them.

So, no matter how bad you think your cholesterol is, and some people have some pretty bad cholesterol out there, there's lots of options for treatment. And just talk with your family provider, if you need a cardiologist or an endocrinologist or a lipid specialist, we're all available in the community to help you.

Host: Well, folks, we trust you are now more familiar with controlling cholesterol. Eric Shoup, keep up all your great work. Thanks so much again.

Eric Shoup: I enjoyed being here. Thanks so much for the opportunity.

Host: Same here. Great to have you on for this very popular topic with people these days, and really for as far back as I can remember. And for more information, please visit prismahealth.org/flourish. If you found this podcast helpful, please do share it on your social media. I'm Joey Wahler. And thanks again for being part of Flourish, a podcast from Prisma Health.