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Healthy Weight Loss Diets |
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Cardiovascular Health, Fibromyalgia, Osteoporosis, Diabetes, High Cholesterol, High Triglycerides,
Acid Reflux,
Heartburn, High
Blood Pressure, Hypoglycemia, Irritable
Bowel, Menopause, Arthritis,
Rheumatoid Arthritis,
Reduce Cholesterol.
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Triglycerides Treatment
Decisions on when to
treat cholesterol abnormalities can be based on two factors: lipid
levels (total cholesterol levels, LDL levels, and HDL levels,) and the
presence of additional risk factors, as follows.
Desirable
lipid levels:
Total cholesterol:
For total cholesterol, desirable levels are below 200 mg/dL. Total
cholesterol is considered "borderline high risk" at levels
between 200 and 239, and "high risk" at levels above 240.
LDL cholesterol:
Optimal LDL levels are less than 100 mg/dL. Near optimal levels are
between 100 and 129 mg/dL. Levels between 130 and 159 are considered
"borderline high risk;" and levels between 160 and 189 are
considered "high-risk;" and levels of 190 and above are
considered "very high risk."
HDL cholesterol:
HDL cholesterol levels below 41 mg/dL are considered low.
Additional
risk factors that modify cholesterol goals:
-
cigarette smoking
- diabetes
- hypertension (high blood pressure)
- low HDL cholesterol
- family history of premature heart disease
- age greater than 45 in men, or greater than 55 in women
- 10-year risk of heart attack greater than 20% (The
10-year risk is calculated from a formula that takes into account the
individual's the lipid levels, and the other "additional risk
factors" on this list.
Based on these two
items (i.e., lipid levels and presence of additional risk factors)
treatment is recommended as follows:
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Risk Category
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LDL
cholesterol goal
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LDL level at
which lifestyle changes should be initiated
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LDL level at
which drug therapy should be strongly considered
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| Heart disease
already present, or 10-year risk greater than 20%, or presence
of diabetes |
less than 100
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100 or greater
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greater than 129
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| 2 or more
"additional risk factors" present (see above) |
less than 130
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greater than 129
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greater than 159
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| 0 to 1
"additional risk factors" present (see above) |
less than 160
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greater than 159
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greater than 189
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What about treatment for high triglycerides?
The new guidelines that
came out 4 years ago (May, 2001,) for the
first time, recommend treating patients who have elevated triglyceride
levels. This recommendation is based on recent analyses strongly
suggesting that triglycerides are indeed an independent risk factor for
coronary artery disease. The decision to treat is generally based
on the triglyceride levels themselves. Normal triglyceride levels
are less than 150 mg/dL. Borderline high levels are 150-199 mg/dl.
High levels are 200 - 499 mg/dL, and very high triglyceride levels are
greater than 500 mg/dL.
For people with
borderline or high triglyceride levels, treatment should emphasize
weight reduction, proper diet and exercise. In some people with
metabolic syndrome medical treatment may be necessary along with proper diet and
exercise.
What is metabolic
syndrome (syndrome X)?
"Metabolic
syndrome" is a recently-recognized set of features that are often
seen together, and that, when present, indicate a significantly
increased risk of developing cardiac disease. Metabolic syndrome
includes the following 5 features: 1) abdominal obesity (that is, excess
fat distributed in the waist - the so-called "spare tire;" for
men, a waist size of 40 inches and for women, a waist size of 35
inches); 2) elevated triglyceride levels; 3) low HDL cholesterol levels;
4) hypertension; 5) fasting glucose levels greater than 109 mg/dL.
The new cholesterol treatment guidelines now recognize the presence of
metabolic syndrome as a significant indicator of high risk of
heart disease. Patients with metabolic syndrome need to be
aggressively treated for their obesity, hypertension, and their lipid
disorders.
What other
"special circumstances" deserve attention?
Patients with very
high LDL cholesterol levels (greater than 189 mg/dL): These patients
often have a genetic form of lipid disorder. Not only do they have a
high risk of premature heart disease without aggressive therapy, but
also their family members should be screened for elevated cholesterol
levels, and those with high cholesterol levels also need to be treated.
Patients with low
HDL cholesterol levels (less than 40 mg/dL): The new
guidelines now recognize low HDL levels as a strong independent risk
factor for coronary artery disease. Many of patients with
low HDL will have diabetes or "metabolic syndrome" (see
above.) They are often overweight and physically inactive.
Other causes of low HDL levels are smoking, very high carbohydrate diets
(greater than 60% of calories), and drugs (anabolic steroids,
progesterone, and beta blockers). Unfortunately, current drug
therapy usually does not markedly increase HDL levels. Treatment for
patients with low HDL levels is usually aimed at weight reduction,
smoking cessation, exercise, and controlling other risk factors (such as
hypertension, LDL cholesterol, and triglycerides.)
How
are elevated cholesterol and triglycerides treated?
The primary method of
treating elevated cholesterol (and triglycerides) is with proper diet,
exercise, and weight loss. Patients who
are obese can often significantly reduce their LDL cholesterol and
triglyceride levels by losing weight.
Cholesterol levels should
be re-measured 3 - 6 months after undertaking these non-pharmaceutical efforts.
What
drugs are used to treat cholesterol and triglycerides?
These drugs include
four major categories:
Bile acid binding
resins: Cholestyramine and cholestipol – these drugs prevent the
cholesterol in bile (the digestive product secreted from the
gallbladder) from being reabsorbed in the gut. Their side effects
include intestinal gas and gallstones, which significantly limit their
usefulness. The bile acid binding resins can also cause a decrease in
absorption of other drugs, and vitamin deficiencies. In addition, these
drugs can occasionally cause significant increases in triglyceride
levels.
Niacin: Niacin
is one of the B vitamins. When used in large doses, it can significantly
reduce LDL cholesterol and increase HDL cholesterol, by mechanisms that
are poorly understood. Its major side effects include skin flushing and
severe itching, along with gastrointestinal disturbances. Nicacin is
very effective, but because of side effects tends to be poorly
tolerated.
Fibric acid
derivatives: Gemfibozil and clofibrate are fibric acid derivatives.
The chief benefit of these drugs is that they lower triglycerides. Their
ability to reduce LDL cholesterol is much more modest. They can cause
gastrointestinal side effects and gallstones.
Statins:
Several statin drugs are now on the market, including lovastatin,
pravastatin, atorvastatin and simvastatin. These drugs inhibit the liver
enzyme HMG-CoA reductase, which significantly reduces the production of
cholesterol by the liver. These drugs result in a significant reduction
in LDL cholesterol, with a modest decrease in triglycerides, and a
modest increase in HDL cholesterol. They tend to be well-tolerated in
general, but can cause elevations in liver enzymes (which therefore need
to be monitored). They can also cause a muscle disorder which can be
severe in rare individuals. The muscle disorder (myopathy) is
particularly likely when statins are used in combination with
gemfibrozil.
Of these drug
choices, the statins are not only more effective than other
categories, they also tend to be much better tolerated. Furthermore, evidence
is accumulating that the aggressive use of statins can actually
arrest the progression of coronary artery disease, and in some
circumstances can be used instead of more invasive procedures such as
angioplasty.
The treatment of
abnormal lipid levels can be summarized as follows: First, dietary
changes, weight loss, and exercise should be tried. If that fails to
restore adequate lipid levels, then most doctors will try statins. If
statins fail, or if they are not tolerated, an agent from another class
of the lipid-lowering drugs can be tried.
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