High cholesterol doesn’t always mean you need statins or super-strict diet, a cardiologist advises
Taking medications, even when your cholesterol is high, is no substitution for regular exercise, working on reducing stress and following a careful diet.
Friends and family often ask me questions about the heart, and a recent query gave me pause.
A slim white woman, age 55, who never has smoked, rarely drinks, eats a healthy diet, walks every day, and does yoga twice a week recently went to her doctor and was told she has high cholesterol. Her LDL (bad) cholesterol is 171 with total cholesterol of 260. (An LDL level above 190 is cause for concern.) Her doctor said she needs to change what she’s eating if she doesn’t want to start taking a statin, cholesterol-lowering medication.
She also has been told she has osteopenia and needs to increase her calcium intake. But she’d rather avoid calcium supplements because they’re constipating.
So, doctors are telling her to follow a high-calcium, high-protein, high-fiber, low-cholesterol diet.
Is that even possible?
And is it even worth trying, given that high cholesterol runs in the family, affecting both her late father (who had a lot of unhealthy habits) and sister (who is a paragon of healthy living)?
The short answer to this question: Taking a pill or following an impossible diet is not always the best approach. Taking medications, even when your cholesterol is high, is no substitution for regular exercise, working on reducing stress, and following a careful diet. The complete answer is below, in a bit more detail:
Does everyone who has high cholesterol need a statin? The answer is no, but if you have diabetes, hypertension, a terrible family history or are a smoker, high cholesterol is more concerning. In the absence of these other risk factors, medication is less helpful.
How much effect does diet really have on lowering cholesterol? There has been a debate in recent years about whether cholesterol in diet really matters, but restricting cholesterol and saturated fats can make a difference. A recent study suggests that cutting back on cholesterol, and eating a few less eggs a week, is of benefit. The closer you come to a plant-based diet, the healthier you will be.
Can menopause affect your cholesterol? Yes, and not for the better. Post-menopause, LDL often goes up, and HDL (good) goes down because of hormonal changes. It is best to recheck these numbers, as they can go up in the decade after menopause, and higher numbers can increase risk.
Does an overly restrictive diet help? Following a diet that does not make sense to you is not going to work. I do not even know what a high-calcium, high-protein, high-fiber, low-cholesterol diet is, but it does not sound as if it tastes very good.
What is the relationship between high cholesterol in families and actually having heart disease? We do not always know. Lots of people have high cholesterol and never have a problem. Concerns about individual risk can be addressed by a test called a calcium scoring CT. This low-radiation scan can decide whether statins will help you. A zero score means the risk of heart disease is almost nil for the next 10 years, so low that statins will not lower it further. The test costs about $100 and is not covered by insurance. In a few years, it is likely that genetic testing will do even more to help assess risk.
If you have a terrible family history of high cholesterol and heart disease, does anything really help other than taking a statin? Studies show that the importance of lifestyle change in someone with a family history of heart attacks is even more important than if you do not have this risk factor. Lifestyle means more than medications, but sometimes you do need both.
Should every woman be on a calcium supplement? Osteoporosis can be helped by increasing calcium in the diet, but supplementing is controversial, as no one really knows what optimal calcium intake should be.
Is my doctor recommending cholesterol medications because he is in cahoots with the pharmaceutical industry? There is a mountain of evidence that after you have a heart attack, stroke, bypass or stent, statins lower risk, and this is not industry propaganda. When it comes to prevention, medications may sometimes be overprescribed, but it is more likely to be from a reluctance by physicians to believe in the ability of their patients to maintain a lifestyle change.
My conclusion: I would not recommend a statin for this woman at this time. Staying active and continuing a healthy lifestyle is key. Seeing a dietitian may help with her diet, but the diet suggested to her is silly, as it is not sustainable. Further cardiac testing such as a stress test is unlikely to provide more information as she already exercises at a high level. Rechecking a lipid panel in the years post-menopause would be helpful to be sure her cholesterol numbers do not skyrocket, as an LDL cholesterol over 190 mg/dl is associated with increased risk. A calcium scoring CT scan might be helpful to further predict her risk.
David Becker, M.D., is a frequent Inquirer contributor and a board-certified cardiologist with Chestnut Hill Temple Cardiology in Flourtown, Pa. He has been in practice for 25 years.