Articles on Medical Diseases and Conditions

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  • Sexual relationships

    Many people are diagnosed with MS at a time when they are, or may be about to become, sexually active in their relationships. The issues associated with how best to manage sexual activity and MS have in the past often proved difficult to discuss with others. However, increasingly, both doctors and other health professionals concerned with MS are aware of the importance of such issues and are able to offer helpful support and advice. In this chapter, we address some of the common worries that men and women with MS, and their partners, may have. Multiple sclerosis – the ‘at your fingertips’ guide contains more information on this subject. We start with a discussion about problems with erections, common issues affecting men with MS, and their sexual relationships.

  • A Diagnosis of High Blood Pressure

    If your doctor diagnoses you as having hypertension, your ?rst reaction may be surprise, because you feel ?ne. That is not unusual. High blood pressure usually has no symptoms, and many people go for years with- out knowing they have it. Your heart, brain, and kidneys can handle increased pressure for a long time, and you can live for many years with- out any symptoms or discomfort. But getting treatment to lower your blood pressure is extremely important, because hypertension is a major risk factor for serious disease.
    High blood pressure can affect your body in six main ways:
    • Atherosclerosis Uncontrolled high blood pressure can cause the walls of the arteries to thicken and become less ?exible. Fatty deposits are more likely to form on the rigid walls, and the chan- nel in the artery narrows.
    • Stroke If a blood clot forms and lodges in a stiffened artery trav- eling toward your brain, it can cause a stroke. If the clot is in an artery that supplies blood to your heart, it can cause a heart attack. High blood pressure may also cause a stroke if a weakened blood vessel ruptures.
    • Aortic aneurysm High blood pressure contributes to the widening of a weakened aorta, and an aortic aneurysm can be fatal if untreated.
    • Enlarged heart High blood pressure forces your heart to work harder. Over time, the muscle thickens and stiffens, or the heart muscle may enlarge and weaken. As it weakens, it pumps less ef?- ciently, and you will feel weak and tired more often. Fluid may back up and congest the lung tissue.
    • Kidney damage The kidneys ?lter waste products from the blood. If the vessels of the kidneys are thickened and damaged,

    your kidneys will begin to fail, causing waste to build up in the bloodstream. Treatment for kid- ney failure requires dialysis, a mechanical means of ?ltering the blood.
    • Eye damage If you have diabetes, high blood pressure can cause the capillaries in your eyes to bleed. This condition, called retinopathy, can eventually lead to blindness.

    These potential complications of blood pressure are genuinely alarming, but remember, blood pressure can be significantly lowered with treatment. The great decreases in death from heart disease and stroke in this country in recent years are partly the result of success- ful treatment of high blood pressure, speci?cally:
    • The incidence of stroke can be reduced by 35 to
    50 percent.
    • The incidence of heart attack can be decreased by
    20 to 25 percent.
    • The incidence of heart failure can be decreased by more than 50 percent.

    The Silent Disease

    Some people think that high blood pressure causes symptoms such as nervousness, sweating, or difficulty sleeping. None of these is a symptom of hypertension, and these are not necessarily related. Many people who look and feel perfectly fit have high blood pressure, while some peo- ple who are overweight, smoke, or show other risk factors for heart disease have normal blood pressure. That’s why the only way to know for sure if you have high blood pressure is to be tested.
    A person with severe, un- treated high blood pressure may have headaches, dizziness, or nosebleeds, but probably not until the condition has reached an advanced, life-threatening stage. Again, even many people with uncontrolled high blood pressure still do not have any of these symptoms. Getting tested and getting treatment are the only answers.

  • Factors That Increase Your Risk for High Blood Pressure

    The vast majority of people—90 to 95 percent—with high blood pres- sure have a type called essential or primary hypertension, which means that the exact cause or causes are unknown. In other people, high blood pressure may occur because of an underlying problem such as a blood vessel abnormality, kidney disease, or thyroid disease.
    However, there are well-known factors that increase your risk of developing high blood pressure or tend to worsen an existing condition. If one or more of these risk factors applies to you, you are at greater risk.
    You may have these factors contributing to hypertension, some of which are not within your control:
    • Gender Men are somewhat more likely to develop high blood pressure until age 70 than women, but after age 70 women are at greater risk.
    • Race Blacks develop high blood pressure more often than whites, and it tends to develop earlier and be more severe.
    • Family history If your parents or siblings have high blood pressure, you are more likely to develop it.
    • Age Generally, the likelihood that you have high blood pressure increases as you age. However, it is not a normal part of aging, and some people never develop it. Men tend to develop it after age
    . Women are more likely to have it after menopause. Other factors are within your control:
    • Weight As your body weight increases, your blood pressure rises.
    • Lack of exercise An inactive lifestyle increases your likelihood of being overweight and of having high blood pressure.
    • Salt Many people with high blood pressure are sensitive to salt;
    eating too much salt raises blood pressure in most people.

    • Unhealthy diet A diet low in fruits and vegetables or high in fat increases your risk of developing high blood pressure.
    • Drinking too much alcohol Heavy regular intake of alcohol can increase blood pressure signi?cantly.
    • Medication Over-the-counter decongestants and nutritional supplements may increase blood pressure. Birth control pills may also increase blood pressure in some women.

  • Measuring Blood Pressure

    Because your heart pumps in pulses, your blood pressure naturally rises and falls with each surge, even when you are at rest. Blood pressure peaks when the heart’s ventricles contract (the pumping or systolic phase) and falls to its lowest level after the contractions (the resting or diastolic phase). To accurately assess blood pressure, you need a reading for both phases, systolic and diastolic.
    You have probably had your blood pressure measured many times—just about every time you have any kind of a physical checkup. The familiar instrument your doctor uses, the blood pressure cuff and pressure gauge, has an unfamiliar name: sphygmomanometer.

    This instrument works by measuring how high the pressure in an artery in your arm can raise a column of mercury, so the measurement is expressed in millimeters of mercury (mm Hg). The reading is always expressed with the sys- tolic (pumping) pressure on the top and the diastolic (resting) pressure on the bottom. A healthy reading in an adult is less than 120/80 mm Hg.

    6

    Checking your blood pressure
    If you have been diagnosed with high blood pressure, your doctor will encourage you to acquire and use a device for monitoring your own blood pressure at home. This is especially important if you are taking new medica- tions or if your drug dose has been changed.

    Healthy adults should have their blood pressure checked at least every two years. If you have not had it checked recently, make an appointment to do so soon. It is an easy, pain- less, and inexpensive test. You can have a reli- able blood pressure check in many different settings—a hospital clinic, a nurse’s office, a company clinic. You may be tempted to consult the free blood pressure testing units that you see at some drugstores or shopping malls, but you should not rely on them alone. They may not be checked regularly for accuracy, and they may suffer from wear and tear. If you try out one of these machines, record the reading and then compare it with a read- ing from your doctor’s of?ce.
    When you know you are going to have your blood pressure checked, you can do several things to help ensure an accurate reading:
    • Do not drink coffee or smoke 30 minutes before the check; both caffeine and nicotine raise your blood pressure temporarily.
    • Try to arrive at your doctor’s of?ce at least 5 minutes before the check and sit comfortably, so you are not feeling hurried.
    • Wear short sleeves.
    Some people have a response called “white-coat hypertension,” which means that their blood pressure actually rises when they are undergoing a checkup. This phenomenon is quite common. If you or your doctor thinks you may be responding this way, you can try having your blood pressure checked in another setting, or you can buy a blood pressure device to do your own reading at home (see page 55). Your doctor can compare your home and of?ce readings to get a clearer idea of your average blood pressure.

    If your doctor is concerned about your blood pressure, he or she will initially take measurements on several different days, because there are so many normal variations. It is not unusual to have a high measure- ment on a single day and then have it return to normal when you are tested again. Your doctor will probably not diagnose you as having high blood pressure unless your measurement is high on two or more read- ings taken at separate visits.
    If your readings are 120/80 mm Hg or greater over several different days, your doctor will evaluate your condition in other ways. He or she will take a detailed medical history to determine if you have other risk factors for heart disease or stroke. He or she may use an instrument called an ophthalmoscope to look at the blood vessels in your eyes. This is the only place in your body where a doctor can directly look at your blood vessels to see if they are damaged. Thickened, narrowed, or burst vessels in the eyes can be another indication of high blood pressure.

    If your doctor diagnoses high blood pressure, he or she may order several tests. These tests are used to determine if there is an underlying cause of high blood pressure, to detect any organ damage, to assess other risk factors for heart disease, and to identify other conditions that might affect the course of treatment.
    In addition to conducting blood tests, your doctor also might order a chest X-ray (see page
    128) to check the size and condition of your heart and lungs. An electrocardiogram (ECG; see page 122) may provide evidence about whether your heart is enlarged and if there is any damage to the heart muscle. It is not uncommon to have a routine ECG in the doc- tor’s office that reveals signs of an enlarged heart or a previously unknown heart attack.
    You may have blood and urine tests to deter- mine if your kidneys are working properly or if there are any underlying problems causing the blood pressure to rise. In rare cases, people may have an intravenous pyelography, a procedure that examines kidney function by injecting a harmless dye into an artery and watching its passage on an X-ray screen. A few people may need more advanced tests to evaluate blood ?ow, such as an MRI (magnetic resonance imaging; see page 141), a nuclear scan stress test (see page 135), or a coronary angiogram echocardiogram.

    How Blood Pressure
    Testing Works

    The instrument used to test your blood pressure has four parts: an inflatable cuff, a pump, a pressure gauge, and a stethoscope. When you have a checkup, the tester wraps the cuff around your arm and inflates it so that the pressure in the cuff is higher than the pressure in your artery. The flow of blood is momentarily stopped and your heart- beat is inaudible through the stetho- scope. As the cuff deflates, the tester checks the pressure gauge as soon as he or she hears your heartbeat again. At this moment, the pressure in the cuff is the same as the pressure in your artery, and the reading is your systolic pres- sure. As the cuff deflates further, the tester listens for the moment the sound of the heartbeat disappears again— when the cuff pressure goes below the resting pressure in your artery. This reading is your diastolic pressure.

  • Just What Is Blood Pressure?

    As your heart pumps blood through your arteries, the moving blood exerts pressure against the arterial walls. This force is measured as blood pressure. Your blood pressure rises normally in response to many everyday in?uences, such as exercise, caffeine, medications, or stressful situations, and then returns to a normal level. But if the pressure in your arteries is consistently higher than is healthy, your heart needs to work harder and your blood vessels and heart can become damaged.
    Blood pressure is determined by the force of the heart as it contracts (systole) and the resistance of the main arteries and smaller arteries (called arterioles) to blood ?ow. The other force is diastole or relax- ation. Healthy arterioles are muscular and highly elastic and stretch eas- ily as blood is pumped into them. Their ready squeezing action keeps blood moving. When the heart is pumping more blood, as during exer- cise, many of the arterioles expand to accommodate greater blood ?ow. Healthy arteries are also wide open, clear of any buildup or obstruction so that blood can ?ow freely. Diseased arteries lose their elasticity, and pressure rises.

  • High Blood Pressure

    Today, high blood pressure (hypertension) is probably the most modi?able common major risk factor for heart disease and stroke in
    the United States. About one out of every three American adults has high blood pressure, and the numbers are increasing as our country ages and becomes more overweight. High blood pressure can cause damage to the heart, blood vessels, and, over time, the kidneys.
    Current ?ndings suggest that high blood pressure is an even more widespread health problem than previously understood. Today, at age 55, even a person who does not yet have high blood pressure has about a 90 percent chance of developing it at some point in his or her life. Further- more, recent evidence shows that the damage to arteries that leads to heart disease, stroke, and other major problems begins at blood pressure levels that doctors once considered normal. Independent of other risk factors such as high blood cholesterol level or being overweight, the higher your blood pressure, the higher your chance of heart disease or stroke.
    About one third of Americans who have high blood pressure don’t know it. Hypertension is often called the silent killer because by itself it does not cause symptoms, but over time it can cause stroke, heart attack, and kidney failure, any of which can be fatal. Most people who know they have the condition still do not have it under control; that is, their blood pressure levels are higher than is considered healthy.

    These numbers make clear how important it is to get your blood pressure checked, and to start as early as possible to prevent or treat the development of high blood pressure. The very good news is that it’s easy to be tested and treated. Even better, high blood pressure is largely preventable.

  • Medications to Lower Your Cholesterol

    If a healthful diet, regular exercise, and weight loss do not bring your total cholesterol or LDL levels down to your target, your doctor may prescribe a cholesterol-lowering medication, or a combination of more than one. You also may need to take these drugs if you have even mod- erately high cholesterol and also have a medical condition such as heart disease, thyroid disease (hypothyroidism), diabetes, or kidney disease. Your doctor will consider your age and family history as well as your risk status (see box, page 21) to determine what target cholesterol level is appropriate for you, and whether drugs are needed.
    If you are at high risk or very high risk, your doctor may recommend drugs to lower your LDL cholesterol aggressively, to less than 70 mg/dL. If you are at moderate risk, drugs will probably be recom- mended if your LDL is higher than 130. On the other hand, drug ther- apy is not necessarily appropriate for everyone—for example, for frail elderly people who have high cholesterol levels but who do not have heart disease or diabetes.
    It is important to discuss your medical history and lifestyle with your doctor before you begin taking cholesterol-lowering medications. Tell him or her about any other medications, vitamins, or herbal supple- ments you are taking. (Some drugs can interact with one another in a harmful way.) You and your doctor will also need to talk about what other illnesses you have, particularly if you have had liver problems, diabetes, gout, ulcers, or kidney or gallbladder disease, because some cholesterol-lowering medications can make these problems worse.

    There are ?ve main types of cholesterol-lowering drugs, each with a different method of action in your body.
    • Statins (or HMG CoA reductase inhibitors). The most com- monly prescribed cholesterol-lowering drugs are statins, which block the activity of an enzyme (HMG CoA reductase) in your body that helps you make cholesterol. As your cholesterol produc- tion slows down, your liver makes more LDL receptors. These receptors attract LDL particles in your blood and further lower your LDL levels. In addition to lowering cholesterol levels, statins may have other positive effects such as reducing in?ammation and improving the working of the cells that line the blood vessels. Many people can take statins without dif?culty, but the drugs can cause side effects in some people such as constipation, abdominal pain, or cramps. These side effects are likely to lessen or disappear the longer you take the drug. Statins are usually taken at bedtime, because the body produces more cholesterol in the evening. If you develop any muscle cramps or muscle weakness, alert your physi- cian because this might represent a more serious side effect. Mus- cle aches affect both sides of the body and commonly occur in large muscle groups such as those in the shoulders and the thighs. While taking statins, you need to have a blood test periodically to make sure your liver is not being affected by the drugs. Examples of statins include lovastatin, pravastatin, simvastatin, atorvastatin, and rosuvastatin.

    • Bile acid sequestrants (or resins). Your liver uses cholesterol to produce bile, an acid involved in the digestive process. These drugs bind chemically to bile in the intestine, preventing the bile from being reabsorbed; the bile is subsequently eliminated from the body in the stool. Your liver responds by using more choles- terol, which is a building block of bile, to make more bile. As a result, less cholesterol is left to enter your bloodstream. Bile acid sequestrants may have side effects such as constipation, stomach bloating, upset stomach, or heartburn. Examples of bile acid sequestrants are cholestyramine, colestipol, and colesevelam.

    • Nicotinic acid (niacin). This product is a form of vitamin B that slows the liver’s production of certain components of LDL. It also can lower triglycerides and raise HDL. Possible side effects of nicotinic acid include ?ushing, upset stomach, a gout attack, or abnormal heart rhythms. The ?ushing can be reduced by taking an aspirin 30 minutes before taking the nicotinic acid. If niacin is prescribed, it should be started at low doses and increased gradu- ally. Alcohol should not be consumed for two hours after taking niacin because of a possible increase in ?ushing. Episodes of ?ush- ing may be curbed with a chewable adult-dose aspirin or liquid ibuprofen (like aspirin, a nonsteroidal in?ammatory product).

    • Fibric acid derivatives (or fibrates). These drugs inhibit the production of the particles that may contain triglycerides and also stimulate enzymes that break down fats. Fibric acid derivatives may be prescribed to lower your triglycerides. They can cause side effects such as upset stomach, vomiting, gas, or headache, and they may increase the risk of gallstones. Examples of ?brates include gem?brozil and feno?brate.

    • Cholesterol absorption inhibitors. This is a newer class of drugs that inhibits the uptake of cholesterol by the small intestine. Eze- timibe is the ?rst drug developed in this category, and it can be given with any statin. Currently, the statin drug simvastatin is manufac- tured with ezetimibe in a combination pill. Ezetimibe is often pre- scribed for people with high cholesterol levels who cannot take a statin. Side effects may include stomach pain, feeling tired, or aller- gic reactions such as swelling in your throat. Inform your doctor promptly if these side effects occur.

    You may not have any side effects at all from your medications, or you may experience some that are not mentioned here. Be sure to tell your doctor immediately if you think you might be experiencing side effects from the drugs you are taking. But don’t stop taking them without checking with your doctor ?rst; going off medication abruptly can make your condition worse. These drugs should not be used during pregnancy (with the exception of bile acid sequestrants) because the effects on developing fetuses are not yet known.

  • Eating to Control Your Cholesterol

    Choosing foods that are low in saturated fats, trans fats, and cholesterol can lower your cholesterol. You might think that cholesterol in food is the major contributor to elevated blood cholesterol, but that is not the case. The biggest culprits are saturated fats and trans fats. The ?rst step toward lowering your cholesterol through diet is to understand the different types of fats in foods and their impact on blood cholesterol.

    Fats That Raise Cholesterol

    Two types of fats are known to raise your cholesterol: saturated fats and trans fats. If you have high cholesterol, current guidelines recommend that you limit your intake of saturated and trans fats to total no more than 7 percent of the total calories you consume in one day. Saturated fats, which your body uses to make bad LDL cholesterol, mostly come from animal products. Beef, veal, lamb, pork, and whole-milk dairy products including butter, cream, milk, and cheeses are all high in sat- urated fat. Plant sources of saturated fats include tropical oils (coconut, palm, and palm kernel oils) and cocoa butter. These foods are also high in dietary cholesterol. However, the fat in cocoa butter appears to be more neutral and less likely to raise LDL levels.
    Trans fat or trans fatty acid is an unsaturated fat, but it can also raise your LDL levels and lower your HDL levels. Trans fats are made when hydrogen is added to vegetable oils to make them solid and longer last- ing. Trans fats are widely used in commercial baking (crackers, cookies, and cakes) and in restaurants, particularly for frying. They also occur naturally in some foods such as meat and whole milk. Recently the Food and Drug Administration mandated that the amount of trans fatty acids in any prepared food product be spelled out on the food label (see sam- ple label on page 94). Also recently, the American Heart Association recommended that people limit their consumption of trans fatty acids to no more than 1 percent of their total calories each day. However, a label may state “0 g trans fat” but still contain up to 0.5 g of trans fats per serving, so to be con?dent you are controlling the amount of trans fats, make sure the label says the product contains no hydrogenated oil or “partially hydrogenated oil.” The New York City Department of Health recently banned the use of trans fats in restaurants in the city.

    Fats That Lower Cholesterol

    Some fats may actually lower your cholesterol. Both polyunsaturated and monounsaturated fats alike have qualities that help lower your cho- lesterol. They are both good substitutes for saturated or trans fats, but you still need to moderate your intake of fats in order to keep down your total calorie intake. To lower your cholesterol, your intake of all fats combined should be 25 to 35 percent of your total calorie intake per day.
    Monounsaturated fats are found in oils and fruits, such as olive oil and avocadoes. In your body, these fats help your body’s cells resist absorption of fat and cholesterol and slow the buildup of plaque in your arteries. Polyunsaturated fats are found in many nuts and seeds, corn, and soybeans and their oils. It is important to recognize that canola oil has the lowest content of saturated fat among the various pressed oils that are available.
    Foods rich in omega-3 polyunsaturated fats may be especially health- ful, reducing your risk of coronary artery disease, high triglycerides, blood clotting, abnormal heart rhythms, and sudden death. The American Heart Association recommends that you eat at least two servings of baked or grilled ?sh, preferably fatty ?sh, each week. Omega-3 fats or fatty acids are found in ?sh, especially fatty ?sh such as sardines, mackerel, lake trout, salmon, and albacore tuna. However, concerns about the high levels of mercury in mackerel, sword?sh, and tuna have led experts to recommend that adults limit themselves to eating no more than one serving of these ?sh per week. A fetus may be especially vulnerable to mercury, so doctors often recommend that pregnant women limit their consumption of mercury-containing ?sh even more. As an alternative to ?sh, several plant sources are rich in omega-3 fats, including ?axseed and ?axseed oil, soy- bean oil, and walnuts. Soy, though high in total fat, is very low in saturated fat and might have a bene?cial effect on lipids. Soy may be consumed in various forms including tofu, soy milk, and edamame beans.

    Dietary Cholesterol

    Cholesterol is found exclusively in animal-based products. Red meat, whole-milk dairy products, egg yolks, and organ meats are especially high in cholesterol. To lower cholesterol, current guidelines recom- mend that you limit your cholesterol intake to less than 300 milligrams per day, on average. Keep in mind that plant-based foods— fruits, vegetables, grains, nuts, and seeds—don’t raise your cholesterol level, so you can eat more of them.

    Fiber

    Eaten as part of a diet low in fat and saturated fats, ?ber can help lower your cholesterol. A high-?ber diet is linked to lower death rates from coronary artery disease and heart attack.

    Soluble ?ber (a type of ?ber that is partially broken down in your intestine) effectively lowers cholesterol about 5 percent by chemically binding to cholesterol-based substances to remove them from the bloodstream. Adding more ?ber to your diet is one means of enhancing the effects of your overall cholesterol-lowering diet. Soluble ?ber is found in oatmeal and oat bran, beans, peas, barley, citrus fruits, straw- berries, and apples. By contrast, the insoluble ?ber found in wheat products has no cholesterol-lowering effects.

    Plant Stanols and Sterols

    Your doctor may recommend that you start using soft margarines con- taining plant stanols and sterols. These substances are the plant equiva- lent of cholesterol, and they may significantly reduce your body’s absorption of dietary cholesterol from other sources. Margarines con- taining these substances are available at most grocery stores. Liquid mar- garine, spray margarine, or soft margarine in tubs are recommended over hardened margarines in sticks, because those contain hydrogenated fat or trans fat.

    Alcohol and Cholesterol

    You may have read about some studies suggesting that moderate use of alcohol may actually raise your good HDL cholesterol. However, the bene?ts are not clear enough to recommend that you start drinking alcohol if you don’t drink now. People who drink in moderation—one drink a day for women, two drinks a day for men, on average—have a lower risk of heart disease than nondrinkers. But drinking in higher amounts is dangerous to your cardiovascular health in many ways, con- tributing to your risk of developing high blood pressure, obesity, and stroke. Also, for women, more than one alcoholic drink per day increases the chances of breast cancer.

  • Interpreting Cholesterol Test Results

    Cholesterol readings are expressed in milligrams per deciliter of blood (mg/dL), and the numbers are classi?ed by level of health risk. Your reading can change somewhat from day to day, and the classi?cations are based on ranges. Of course, being in a high range doesn’t guarantee that you will develop heart disease, nor does being in a low range assure that you will not. The impact of your cholesterol readings on your over- all risk for heart disease or stroke depends on other factors, including your family history, conditions such as diabetes or high blood pressure, and other health habits such as smoking or physical inactivity.

    Total Cholesterol Level

    The total cholesterol level is the most common screening measurement. About half the adults in the United States have a reading in the desirable range of 200 mg/dL or less, indicating a lower risk of developing heart disease. Even if you are at this level, it’s still a good idea to eat foods that are relatively low in saturated fats and trans fats, and to exercise regu- larly. Continue to get a full lipoprotein pro?le every 5 years.
    The total needs to be interpreted, along with how the cholesterol is packaged in the bloodstream. A total level of 200 to 239 mg/dL is called borderline high and places you at up to two times the risk of heart attack

    The total needs to be interpreted, along with how the cholesterol is packaged in the bloodstream. A total level of 200 to 239 mg/dL is called borderline high and places you at up to two times the risk of heart attack as someone with a reading below 200 mg/dL. Your
    doctor will discuss this reading and the rest of your pro?le with you, as well as other factors that con- tribute to your risk. Some people, such as menstru- ating women before menopause or young, active men, may have an elevated total cholesterol reading but may not be at high risk for heart disease. The reason is that although the total cholesterol is ele- vated, it is the HDL, or good cholesterol, that is ele- vated, and LDL, the bad cholesterol, is within target range. Talk to your doctor to interpret your results.

    If your total cholesterol is above 240 mg/dL, you are more than twice as likely to have a heart attack as someone with a borderline high reading. You are also at a higher risk of stroke. Again, you need to dis- cuss your overall pro?le with your doctor and get started trying to bring your level down to a healthy target.

    HDL Level

    HDL is the good cholesterol that, at higher levels, appears to reduce your risk of heart disease. People with a low level of HDL are at increased risk for heart disease. In the average man, HDL levels range from 40 to 50 mg/dL. In an average woman, they are higher, 50 to 60 mg/dL, because the female hormone estrogen raises HDL. After menopause, a woman’s HDL levels may fall, increasing her risk of heart disease. For a man or a woman, a reading below 40 mg/dL is considered too low. People who are overweight or physically inactive are more likely to have a low HDL reading.
    If your reading is low, your doctor may recommend that you get more exercise, lose weight if you are overweight or obese, and quit smoking if you are a smoker. Although treatment for high
    cholesterol usually focuses on lowering LDL

    cholesterol, doctors are placing increasing emphasis on the importance of raising HDL as well. A key strategy for raising your HDL choles- terol levels is eating more ?sh and less red meat. Further, consuming omega-3 fish oil reduces triglycerides and raises HDL.
    The ratio of total cholesterol to HDL is a more meaningful indicator of risk than is total

    HDL Guidelines

    HDL Level (mg/dL) Category

    Less than 40 Low
    40 to 59 Desirable; the higher the better
    60 and above High

    cholesterol alone. This is especially true because a normal total choles- terol number (less than 200 mg/dL) may pose increased risk if it is asso- ciated with a low HDL level. To calculate that ratio, divide your total cholesterol by your HDL value. A number greater than 5 shows a higher risk level. The lower your ratio is, the lower your risk of heart disease is. Try to keep your ratio lower than 4 to 1.

    LDL Levels

    LDL is the harmful cholesterol that can slowly build up plaque in the arteries. Of your lipid readings, it is the single most important indicator of your risk of cardiovascular disease. A reading of less than

    100 mg/dL is considered optimal, but not everyone needs to be that low if their other risk factors are under control.
    You and your doctor will talk about your target LDL reading level in the context of other aspects of your cardiovascular health and other risk factors. Medical conditions that increase your risk include high blood pressure (120/80 mm Hg or higher) or being on med- ication for high blood pressure, other vascular disease, type 2 diabetes (fasting blood glucose of

    •126 mg/dL or higher), or having had a heart attack. Other risk factors are:
    • Smoking cigarettes or long-term exposure to second-hand smoke
    • An HDL reading of less than 40 mg/dL

    • A family history of early heart disease (heart disease in your father or brother before age 55 or in your mother or sister before age 65)
    • Age (45 years or older if you are a man; 55 years or older or menopausal if you are a woman)
    • Menopause, at any age
    • A sedentary lifestyle

    To lower your LDL reading, a diet low in saturated fat, trans fat, and cholesterol and high in ?ber is your ?rst step (see below and pages
    30–32). You also need to lose weight if you are overweight, and get more exercise. If your level of LDL is high, however, drug therapy may be started while you work on lifestyle changes. Lifestyle measures will go a long way to improve your LDL level and condition your heart and blood vessels. But if they do not bring your reading down to your tar- get, your doctor may prescribe medication (see box page 244). A com- bination of cholesterol-lowering drugs and lifestyle changes will bring LDL levels down in most people.

    Triglycerides

    A high triglyceride level may contribute to your risk of developing heart disease, but it is not clear to what degree high triglycerides alone are a risk factor. Doctors do know, however, that a combination of high LDL level and high triglyceride level raises the risk of a heart attack to a greater extent than either one does on its own. People with high triglycerides are often obese or have low levels of HDL, high blood pressure, or diabetes. Extremely high triglyc-
    erides (more than 500 mg/dL) can lead to a life threatening in?ammation of the pancreas called pancreatitis.
    If you have an elevated triglyceride reading, you will benefit from staying at a healthful weight, eating a diet low in saturated fat and trans fat, limiting intake of sugar and other car- bohydrates, drinking in moderation if at all (see page 97), and exercising regularly. You should also have a fasting blood sugar test to monitor for early signs of diabetes. Elevated triglycerides can be a sign of meta- bolic syndrome, also called insulin resistance syndrome.

  • Testing Cholesterol Levels

    High cholesterol does not cause any symptoms, so people can have excessively high levels without knowing it. High blood cholesterol (de?ned as a level of 240 mg/dL or higher) is among the most impor- tant risk factors for developing heart disease. In countries such as Japan, which until recently had cholesterol levels averaging only 150 mg/dL, heart disease has been very rare.
    All adults over the age of 20 should have their cholesterol measured at least once every 5 years with a blood test called a full lipoprotein pro- ?le. Children in families with premature heart disease may be screened starting at age 2. A full lipid pro?le measures not only the total choles- terol but also HDL and triglycerides. Your doctor looks at all of these numbers, as well as your other risk factors for heart
    disease, and then can use a risk assessment tool to estimate your chances of having a heart attack in the next 10 years. Knowing your risk enables you to take steps to improve your cardiovascular health and lower your chances of heart disease and stroke.
    To have your cholesterol tested, you need to go to your doctor or a medical laboratory. The results from tests performed at shopping centers or health fairs are not as reliable as having your blood sample analyzed at an approved labora- tory. Reliable testing requires a fasting blood sample. A nonfasting sample does not allow an accurate determination of LDL, which is the most important indicator of your heart attack risk. You should do the following to prepare for the blood test:
    • For 10 to 12 hours before testing (often overnight), you may not eat or drink any- thing except water.
    • You can eat as you usually do until 10 to 12 hours before the test.
    • You might be asked not to drink any alcohol for several days before testing, because alco- hol can affect triglyceride levels.

    Home Cholesterol Testing

    You may see home cholesterol testing kits for sale in some drugstores. Some measure only total cholesterol, or only total cholesterol and HDL. At least one is designed to test HDL, LDL, triglycerides, and total cholesterol. There is no harm in trying one of these devices, or having your choles- terol checked at a health fair, but these tests do not take the place of a laboratory-analyzed lipoprotein pro- file (which requires you to fast before the test).
    If you try one of these methods and the results indicate that your total cholesterol is 200 mg/dL or more, fol- low up with a full profile done by trained professionals.
    Most laboratories do not measure your LDL directly but calculate it by subtracting your HDL from your total cholesterol level, then subtracting one-fifth of your triglyceride level. This figure is your LDL. In cases of markedly elevated triglycerides, direct testing of LDL is needed.

    • If you are sick on the appointed day, the test should be rescheduled.
    • Before the day of the test, check with your doctor as to which of your regular medications, if any, you should take at home in the morning.