Heart of the Matter Health Article

A year ago, Alabama pediatrician Laura Sawaya-Cortez thought she knew just about everything there is to know about cholesterol—except her own numbers. "I didn’t want to know," she now admits, since she suspected they were probably too high. Ten years earlier, when she went to a local cholesterol-screening program, her numbers were above normal. "But I was in my mid-twenties then and it wasn’t something I worried about," she says. Last March, motivated by her family history, she finally had her numbers checked with a fasting blood test—and discovered that they were well into the danger zone.

You might think a doctor would follow her own doctor’s advice. But when Sawaya-Cortez’s physician suggested that she start taking a cholesterol-lowering statin drug, she said no. Or at least, not yet. Before she began a medication that she might have to take for the rest of her life, she wanted to see if she could bring the numbers down herself, following the familiar advice that many physicians give their patients. She and her husband cut way back on red meat. They started eating more fish and turkey and switched from whole milk to soymilk. They helped themselves to lots of fruits and vegetables. And within a few months her total cholesterol had dropped from 226 to 177, landing firmly in the the safe zone. Her LDL (bad) cholesterol was down an impressive 50 points, from 161 to 111. "Frankly, I was amazed. I wouldn’t have thought it was possible."

Stories like hers might once have inspired Steven Peterson, 55, a business consultant in northern California. Like Sawaya-Cortez, the last thing he wanted to do was take drugs after he learned that his cholesterol numbers were through the roof. "I tried everything. Oats for breakfast. Soy protein smoothies for lunch. No red meat. Olive oil instead of butter. Nuts for snacks. When I read somewhere that broccoli sprouts might lower cholesterol, we actually started growing them in a window garden in the kitchen."

No luck. When Peterson went back to have his cholesterol rechecked after six months, it was slightly higher than before. He left the doctor’s office with a prescription for Lipitor, one of the family of leading cholesterol-lowering drugs called statins.

Abnormal cholesterol levels remain at the top of the list of serious risk factors for heart disease. Based on the current guidelines, nearly 107 million Americans are now believed to have cholesterol levels high enough to put them in danger of heart disease and stroke. Some, like Peterson, may have to go on medication. But many others, like Sawaya-Cortez, could bring their numbers into line simply by adopting a healthier diet and finding time for a little more exercise.

Too many people aren’t even giving it a try, experts say. Why bother with the hassle when all you have to do is pop a daily pill, people tend to think. And given how little time most physicians have to counsel patients about healthy eating these days—and how difficult it is to get people to change—many doctors are taking the easy way out and simply writing a prescription. "Dietary and lifestyle approaches have been all but abandoned," says Margo Denke, M.D., a clinical professor at the University of Texas Health Science Center in San Antonio, who in past years helped draft the nation’s official cholesterol guidelines. "And that’s really a shame."

It is a shame—for several reasons. First, the benefits of eating wisely go way beyond lowering cholesterol. In some studies, adopting a healthier diet has lowered heart-disease risk dramatically, even when cholesterol numbers don’t budge. What’s more, making a few changes to the menu may be easier than taking a daily pill for the rest of one’s life. The latest generation of cholesterol medications, called statins, only work if you take them every day. Many people don’t. Surveys find that after a year, as many as two out of three have stopped filling their prescriptions. And once the drugs are discontinued, especially if people’s diets remain the same, cholesterol levels zoom back up.

And let’s face it, many people with high cholesterol don’t change the way they eat. It’s not unusual to sit down to a hearty dinner with someone who boasts that because he’s on a drug, he can eat anything he wants. "Wrong, wrong, wrong," says Scott M. Grundy, M.D., director of the Center for Human Nutrition at the University of Texas Southwestern Medical Center in Dallas, who helped formulate the latest National Cholesterol Education Program guidelines. "It’s not a matter of either/or, of drugs versus diet. Taking cholesterol-lowering medication doesn’t mean you can forget about diet. By eating a healthier diet, you can lower your risk even further. And if you’re on medication, you may be able to get by with a lower dose."

What’s on the menu?

It’s been more than 50 years since researchers first linked diet, high cholesterol levels and heart disease, and you’d think the experts would agree on the healthiest menu. Alas, there’s still plenty of controversy. Lately, in fact, nutrition researchers say there is no single ideal diet. "What we’re beginning to understand is that there is no one-size-fits-all diet to lower heart-disease risk," says Robert Knopp, M.D., a leading cholesterol expert at the University of Washington in Seattle. "Different people respond to different diets in very different ways."

Part of the change in thinking stems from a more sophisticated understanding of cholesterol. "Fifteen years ago, all we looked at was total cholesterol," says Debbie Strong, dietitian at the Ochsner Clinic Foundation’s Heart and Vascular Institute in Louisiana. Today it is known that LDL cholesterol (low-density lipoproteins) is especially harmful, because it tends to accumulate on blood vessel walls as plaque. Another form, HDL cholesterol (high-density lipoproteins), is beneficial, because it helps ferry the bad (LDL) cholesterol out of the body. Research has revealed that measures of triglycerides, a form of fat particles in the blood, are also linked to heart-disease risk. Today, LDL, HDL and triglyceride levels are considered far more important than total cholesterol.

And that’s where evaluating diets has proved trickier than anyone imagined. Some diets, like very-low-fat regimens, are effective at bringing down LDL-cholesterol numbers, but they often lower beneficial HDL as well and raise triglycerides—a dangerous combination of negative effects. Higher-fat diets keep HDL from falling, but they usually don’t lower LDL as far.