By Krista Scott-Dixon, PhD

With an aging population and rising rates of cardiovascular diseases such as heart attack and stroke, most people in North America have at least some inkling of what cholesterol is, and that high cholesterol is bad for their heart health. However, few people know what cholesterol is, what it does, or what role it plays. This recently released report from the Johns Hopkins School of Medicine provides a 7-point, easy-to-understand guide to cholesterol and its role in disease.

Here are the 7 elements:

1.   Know your target cholesterol levels

This section explains what cholesterol is and what it does in the body. Cholesterol is made by the liver (although we can also eat cholesterol in our food) and does a number of important things in the body. For example, it helps the body make particular hormones such as estrogen, and is an important part of the membranes that encase the body's cells.

Cholesterol cannot get to where it needs to be on its own, so it hitches a little ride on 3 types of lipoproteins:

• Very-low-density lipoprotein (VLDL)
• Low-density lipoprotein (LDL)
• High-density lipoprotein (HDL).

In fact, when we talk about cholesterol levels, we are actually talking about measuring levels of these lipoproteins. HDL, often known as good cholesterol, is seen as beneficial because it tidies up cholesterol as it goes, returning it to the liver. LDL, often known as bad cholesterol, can be a problem because it can accumulate and help form plaque on artery walls.

Like a hallway cluttered with junk, this buildup can then impede blood flow to the heart by narrowing the arteries or enabling the creation of a blood clot, both of which are bad news for the heart. The report provides a chart of what things you should test to check your cholesterol and blood lipid levels, and what the ideal values are.

2.   Focus on the right fats

Dietary fats have gotten a bad rap in recent years, and people assume that cutting out all dietary fat will make them healthier. In fact, says the report, it is the type of fat in the diet that is important. Saturated fats and processed trans fats should be avoided, while mono- and poly-unsaturated fats, particularly omega-3 fatty acids such as fish oil, should make up a moderate dietary fat intake.

3.   Make the most of cholesterol-busting foods

This includes foods rich in fiber, good fats, plant sterols and stanols, and (with some hesitation) soy products.

4.   Reduce cholesterol with medication

This section explains how the standard cholesterol-lowering medications work, how to take them, and how to choose one that might be right for you.

5.   Consider combo therapy to reduce cholesterol

Combining particular medications and supplements (for example, niacin, vitamin B3, and statin drugs) both enhance the overall effect as well as lower the risk of potentially serious side effects.

6.   Boost your HDL - for multiple benefits

As one character yells at a concert in the mockumentary film FUBAR, "Turn up the good! Turn down the suck!" Much of the report focuses on lowering the bad cholesterol, but let's not forget bringing up levels of the good cholesterol.

7.   Remember your ABCs

This is a handy checklist for strategies that can help prevent heart attacks:

1. • Aspirin - low doses daily, if appropriate
   • Blood pressure - keep it below 120/80 if possible
   • Cholesterol - keep the bad stuff down, keep the good stuff high
   • Diet and weight control
   • Exercise.

Overall, this is a nice, comprehensible report that is accessible to most readers and a handy reference guide for trips to the doctor in case you can't remember the difference between your 130mm Hg and your 130mg/dL.

As a lifestyle and fitness educator, however, I feel slightly uncomfortable with the report's overt focus on medication as a primary solution. While the report makes some excellent nutritional suggestions (particularly about fat intake), and notes that "lifestyle measures can have a greater impact on preventing coronary heart disease and heart attacks than on practically any other disorder" (7), it does seem to imply that people concerned about cholesterol should make medication a central part of their treatment. For example, it suggests that "as many as 36 million people [in the United States] should be taking cholesterol-lowering medications. Yet only 12 to 15 million of them are currently taking such medication, and many (probably most) are taking too small a dose." (1)

In this vein (pardon the pun), the report outlines a wide range of medication options. Although informative, it may leave the reader with the impression that one has to consume a handful of pills to keep heart-healthy. Given the massive subsidization of medical research by pharmaceutical companies, it is a good idea for consumers to be as critical as possible and ask lots of pointed questions about how and why they should (or shouldn't) be taking medications.

Moreover, given that many of these medications may be taken long-term, patients (particularly those whose immediate risk is not dire) should also investigate a variety of options before committing to the cost and physical impact of taking drugs every day. Side-effects of statin drugs, while rare, can be severe and include:

• Myopathy - chronic muscle diseases or more mildly, muscle pain and fatigue
• Rhabdomyelosis - a potentially fatal condition in which the body isn't able to properly clear the waste products of muscular activity
• Myoglobinuria and Acute renal necrosis - kidney damage and death (Moosman and Behl 2004).

One medication (cerivastatin, aka Baycol), was voluntarily removed from sale in the United States in August of 2001 after severe occurrences of these types of side-effects among users, including approximately 100 reported deaths linked to the drug's use (Pasternak et al 2002).

Some research has also questioned whether there is even a direct link between treating cholesterol levels and lowering the risk of heart attack—in other words, will keeping your bad cholesterol levels down through drugs ultimately prevent you from keeling over? (Ravnskov 2002) Certainly, it never hurts to be curious and skeptical when considering a long term medication regimen.

While the report alludes to fruit and vegetable intake, it does not mention much about the role of antioxidants. Emerging data suggests that antioxidants, when consumed in food format (rather than as supplements, as some disappointing studies on beta-carotene, vitamin C, and vitamin E have shown), can help lower bad cholesterol and elevate good cholesterol.

Antioxidants, along with omega-3 fatty acids, may also play an important role in controlling the inflammation that helps enable arterial plaques and other chronic conditions. Antioxidants are found in colorful fruits and vegetables (such as dark leafy greens and citrus fruits) along with other sources such as red wine, green and black tea, and cocoa—good news for those of us who love a little dark chocolate and the occasional shiraz! Although the contribution of dietary antioxidants to a cholesterol treatment plan can be modest, it should not be under-emphasized in a multi-factor therapy approach.

Nevertheless, the report certainly reminds readers that lifestyle changes are important. Regular activity and good nutrition have effects that go far beyond symptomatic cholesterol levels, which is why it is essential to include them in any wellness program. Many of these changes are relatively easy for most people to understand and do. This includes:

• Quit smoking (OK, well, at least this one is easy to understand)
• Increase regular physical activity
• Lose weight
• Improve the quality of your diet
• Drink alcohol in moderation.

The medication component (considering appropriate, targeted drug therapy) is slightly more complicated. People should be encouraged to ask lots of difficult and probing questions of their doctor. Do I need this? Why? How long do I have to take this? What other things can I do? While the average person can't be a medical expert, they can certainly make like a 3-year-old, ask lots of "why" and "how" questions, and not stop until they feel confident that all of their inquiries have been answered.

One element I would also liked to have seen in this report is stress reduction. Research suggests that mental and emotional stress, such as depression and anxiety, can actually have notable effects on blood cholesterol and overall cardiovascular health (for example, Bachen et al 2002).

The report focuses on reducing cholesterol, and so its suggestions are aimed at controlling levels once they become a problem. However, as always, prevention is the best medicine. Keeping cholesterol and other things like blood pressure in a healthy range is a lot easier than bringing it down once it is out of control.