The good, the bad and the ugly cholesterol

Eight months ago when I was diagnosed with high cholesterol, I vowed to try to reach safer levels without taking prescription statin drugs.

Today, my cholesterol levels are improved.

But I'm still not sure I'm on the right track.

Figuring out what you need to know about cholesterol and heart disease is like putting together one of those jigsaw puzzles with 1,000 tiny pieces.

In the end, I realized that the "high" cholesterol levels I started out with in December may not have been so alarming, given my own healthy diet and lifestyle.

Assessing heart-disease risk is very individual. What works for me may not work for you. I can't emphasize that enough.

To be safe, talk with your doctor and health-care providers. But maybe you can learn a few things from my journey. Here's what happened:

This year, my family doctor recommended that I start taking a statin drug after a blood test showed that two of four cholesterol levels were higher than recommended.

My total cholesterol was 258 milligrams per deciliter of blood. (National guidelines say a total cholesterol of less than 200 is "desirable.")

LDL, the so-called "bad" cholesterol, was 169. (Less than 100 is considered "optimal.")

My other two cholesterol measurements were fine. HDL, the so-called "good" cholesterol, was 70 (higher than 60 is good). Triglycerides, another form of fat in the blood, measured 93 (less than 200 is recommended).

I thought the recommendation to take drugs was premature. At 59, I'm healthy and I've made it through life without prescriptions, except for a few antibiotics and pain killers.

I knew that statins can cause muscle problems and liver damage. And I knew that having high cholesterol doesn't necessarily mean I'll develop heart disease. More than half of the people who have heart attacks have normal cholesterol under traditional testing.

So for three months, I tried to improve my cholesterol by eating healthier foods and increasing my exercise. I ate a lot more oatmeal and other whole grains, high-fiber fruits and vegetables, and fish, especially salmon. I ate no red meat and avoided fried foods and desserts for the most part. And I went to the gym more.

When I wrote an Observer column about my plan in February, I heard from lots of people trying similar non-drug approaches. They made all sorts of suggestions, including organic apple cider vinegar mixed with honey and orange juice.

The blood tests

I also heard from Dr. Matthew Acampora, a Charlotte internist, who recommended a blood test from the Berkeley HeartLab in California to measure other markers, in addition to cholesterol, that indicate heart disease risk.

After three months on my diet-exercise plan, I went to Acampora for a blood test. The Berkeley lab analyzed it for cholesterol and other markers, including genetic factors and certain hormone levels and agents, such as C-reactive protein. That's associated with inflammation in the body which has been linked to heart disease. The test cost me about $150 out-of-pocket, after insurance.

The new cholesterol results were disappointing: Both total cholesterol and LDL had gotten worse.

Other markers, including C-reactive protein, were all normal. It was reassuring to know that I didn't have other undetected risk factors for heart disease. So the test confirmed what I already knew: I am eating a healthy, high-fiber diet and have a healthy lifestyle.

Acampora said I'm probably "genetically predisposed" to high cholesterol and should take a statin drug - basically the same thing my primary-care doctor said.

That wasn't the answer I wanted.

The natural supplements

After that, I turned to pharmacist Kim DeRhodes at the Carolinas Medical Center-Morrocroft pharmacy. She's trained in alternative medicine and the use of herbs and natural supplements. Her consultation was free with a $25 purchase from the drug store. I spent about five times that.

DeRhodes recommended supplements that I now take daily. I took her recommendation about brands that had received positive evaluations by the independent testing laboratory, ConsumerLab. Because supplements are not regulated by the U.S. Food and Drug Administration, quality can vary wildly.

For heart health, I take fish oil from Nordic Naturals, Vinco's red yeast rice and Nature Made's Cholest Off, a supplement that contains stanols and sterols usually found in plants. DeRhodes also recommended several supplements that had nothing to do with cholesterol - vitamin D, a multivitamin and calcium with magnesium.

It's a lot of pills, some of them huge, twice a day. But I thought I'd give it a try.

DeRhodes agreed I should try to avoid statin drugs. And she cited a recent study published in the Annals of Internal Medicine to support her recommendation to use red yeast rice, a by-product of cooked rice on which red yeast is grown. Red yeast rice naturally contains statin compounds that are used to make prescription statins.

The study found that red yeast rice in supplement form was effective in patients who had been unable to take statin drugs because the drugs caused muscle problems. The study also found that that red yeast rice did not cause liver impairment.

Three months later, in July, I got my blood checked for $25 at a YMCA health center. (Nurses there emphasized that the test should be taken after a 12-hour fast, something my primary-care doctor's office neglected to mention.)

I was pleased by the change:

Total cholesterol fell from 258 to 213

LDL fell from 169 to 128.

HDL stayed at 70.

Triglycerides were 74, a decrease but still in the normal range.

Before declaring victory, I called Dr. Evangeline Lausier, director of clinical services for Duke Integrative Medicine in Durham, to get her opinion about what I had done.

She surprised me.

"Forget the total cholesterol," Lausier said. LDL is the number to watch.

But not everyone should aim for the "optimal" 100 LDL, she added.

Your LDL goal depends on individual risk factors for heart disease and stroke.

"It's only patients at very high risk for heart disease who need to get below 100," Lausier said. "There is no evidence-based guideline that recommends that average-risk patients should get their LDL below optimal."

Here I was, trying to get my LDL below 100 and my total cholesterol below 200 - what my doctors had been recommending - when that isn't the goal outlined in the National Cholesterol Education Program for people like me.

Except for my age, over 55, I don't have any other risk factors for heart disease. I'm not overweight. I don't smoke or have diabetes. I've never had a heart attack or a stroke. And I don't have a family history of early heart disease.

Also, because my HDL is high, I can subtract one risk factor from the list that is used to set LDL goals.

National guidelines state that people like me - with zero to one risk factor - should aim for an LDL of less than 160.

So I wasn't that far off to begin with. And after taking the supplements, my LDL is within the goal.

The guidelines say drug therapy is "optional" among low-risk individuals with LDL greater than 160, and that's only if "first-line therapy" of lifestyle changes have been given an "adequate trial" without reaching the goal.

For most people with zero or one risk factor, the guidelines say drug therapy is recommended when LDL is greater than 190. That's far different from the below-100 target I started with.

Many doctors don't make these distinctions.

Interpret the risks

I'm more convinced than ever that, based on my own risk profile, I don't need statin drugs right now.

Fish oil has anti-inflammatory effects that reduce the risk of heart attack, Lausier said. Plant stanols and sterols in pill form probably don't reduce absorption of cholesterol as well as the real stuff in fruits and vegetables, Lausier said.And red yeast rice? Because supplements are not regulated by the FDA, it's not easy to know how much red yeast rice those products contain.

For now, I'm keeping fish oil, red yeast rice and Cholest Off in the brands recommended by the pharmacist.

I'll ask my doctor to check my liver function. And I'll definitely keep watching my diet and exercising often.

For the rest of you, I'll repeat what Lausier said.

It takes willpower and determination to lose weight, exercise daily, quit smoking or make other changes to lower heart-disease risk. "Every case is different," she said. "There are some situations where nothing but a statin will get you to your goal."