Sharon Weems did something in 2009 that most Americans in her situation can't seem to manage: She lowered her cholesterol significantly, and without the help of medication.
It all started after a regular checkup, when her doctor told her she was headed toward major heart disease and diabetes if she didn't make some changes.
"I got a good scare," said the then-43-year-old mother of three. "I need to be around for my kids."
The Largo woman changed her diet and started working out. In eight months, she lost 80 pounds, lowered her blood pressure and reduced her diabetes risk.
And she saw her total cholesterol drop from 250 to 165, well within a healthy range for her.
"Weight loss is a very effective tool for lowering cholesterol," said Dr. Corey Evans, a St. Petersburg family practice physician who is not involved in Weems' care. "If overweight patients with high cholesterol lose serious weight, their cholesterols plummet."
But when lifestyle changes don't work, you may be faced with a difficult medical decision.
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One-quarter of all Americans over age 45 take drugs known as statins to lower their cholesterol. Used correctly by people at high risk of heart attack (particularly those who've already had one), the drugs have been shown to save lives.
But they often must be taken for years, and even the rest of your life. There are different types of statins, prescribed based on how much of a cholesterol reduction you need, and the cost can range from about $10 to $200 a month, according to Consumer Reports. (With Lipitor, the biggest of the branded statins, going generic, prices could come down in coming months.)
Statins can have side effects in a minority of users, including muscle pain and cognitive impairments. So it's an important decision, and not everyone with elevated cholesterol should be on one of these powerful drugs. Much depends on risk factors, such as age, gender, smoking history and whether a person already has heart disease.
February is American Heart Month, so you'll be hearing a lot of good advice about finding out your numbers for blood pressure, body mass index and cholesterol - and then taking action, if needed.
But while blood pressure and BMI are pretty straightforward, cholesterol can be more complicated. You need more than your total number, so those quickie finger prick tests offered at health fairs don't tell enough of the story.
"Most of us don't even look at total cholesterol anymore. That number doesn't mean a lot to me," said Tampa General Hospital interventional cardiologist Stephen Mester. "You can have a reasonable total cholesterol, but your LDL (the "bad cholesterol'') can be significantly higher than what we like."
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While blood cholesterol is made up of many different components, doctors are most concerned with the big three: HDL, LDL and triglycerides. The American Heart Association offers the following tips:
- HDL, known as the good cholesterol, should be 60 or higher for most Americans
- LDL, known as the bad cholesterol, should be less than 100 or less than 70 if you have other risk factors for heart disease. But if you are at low risk of a heart event, you could be safe with a higher number than 100.
- Triglycerides should be less than 150 for most adults or less than 100 for high-risk patients.
Lifestyle changes - altering your diet, exercising, not smoking and limiting alcohol and foods with added sugars - can all help improve your numbers, particularly regarding triglycerides and HDL.
But LDL, which can build up in coronary arteries and cause blockages that may lead to heart attacks and strokes, can be particularly stubborn. Statins can prevent and, in some cases, reverse blockages.
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Tamma Phillips of Oldsmar knows all about coronary blockages. In 2006, at age 53, she had two blocked arteries that caused a massive heart attack. "It hit me like a ton of bricks. I had the classic symptoms, chest pain so intense I could hardly breathe, and I went down. I knew it was a heart attack," said Phillips, who is now 58.
She was overweight and didn't exercise, and her total cholesterol was over 300.
"Once it sunk in that I could have died, it scared me enough that I knew I had to make some immediate changes."
Phillips went to a cardiac rehabilitation program, started exercising, changed her diet, lost 30 pounds and took her medication, including a statin.
"My cholesterol came down within 30 days. I was shocked. It came down to 190," Phillips said. "But it wasn't just the medication. During that time, nothing passed these lips that wasn't on the approved list."
Changing to a heart-healthy diet may bring LDL down by 20 percent, according to Dr. Patrick Cambier, a Morton Plant Hospital interventional cardiologist. "But that's only in a very motivated person.''
The big concern is preventing heart attacks in high-risk people - particularly those who have already had a heart attack, for whom the value of statins is most proven.
"Diet changes alone don't reduce the risk of cardiac events like heart attacks in these people," said Cambier. "Statins clearly do. A combination of a statin with diet and exercise is best."
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So who should be on a statin?
"If you've already had a clinical event, there is no doubt. In my practice, you don't give diet and exercise alone a chance. You go with the statin," Cambier said.
Patients who haven't had angina or a heart attack - but who have cardiac risk factors and know they won't make serious lifestyle changes - may also opt to go straight to a statin.
"I ask them, 'Is this (diet and exercise) something you can maintain?'" said TGH's Mester.
"If that patient can't change and says 'I can't do it,' I will start the medication. We have to treat who they are," said Mester.
But again, you need to weigh the benefits against the risks. By some estimates, among people who have high cholesterol but otherwise are not at high risk, 100 would have to take a statin for several years to prevent one heart attack. Other experts say such figures understate the potential benefit.
At any rate, positive lifestyle changes carry all the benefits and none of the risks.
For those willing to try changing, "a three-month trial is reasonable," Mester said. "After three months, you need to assess their cholesterol numbers and lifestyle and decide on the next step. If their LDL is greater than 100, you may have to consider medication."
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Almost 10 years ago, Helen Harvey, now 64, was diagnosed with a dangerously irregular heartbeat. At the same time, doctors discovered that the thin, active nonsmoker also had high cholesterol.
"It was close to 400. I was in shock and wanted to know why this was happening to me," the St. Petersburg woman said.
She tried changing her diet, but after a year, she was put on a statin.
"I had some reservations. I'd heard some things about statins,'' she said.
Statins work by slowing the liver's production of cholesterol. They also may affect several enzymes in muscle cells that are responsible for muscle growth. That could account for the most common side effect of statins, muscle pain or weakness.
Digestive problems are possible. More seriously, the drugs have been linked to liver damage and Type 2 diabetes.
That's why your first option should be lifestyle changes, if possible, experts say. But for people truly at risk of a heart attack, experts agree that the benefits of statins outweigh the risks. And it's crucial for patients to keep seeing their doctor for lab tests to make sure they don't develop problems such as liver damage.
"Don't put that monitoring off,'' Mester said. "It contributes to the safety of the drug."
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Managing cholesterol is a lifelong commitment.
After her initial weight loss, Sharon Weems regained 20 pounds, and a recent blood test revealed that her cholesterol is also up, but still below 200. She just started a new exercise program sponsored by her employer, Largo Medical Center, and is working to bring all her numbers down, without medication.
Helen Harvey has maintained a healthy diet and a low body weight and exercises every day. With the help of a statin and niacin, her numbers are enviable (HDL 73, LDL 56, triglycerides 50). She reports no side effects from the medication.
Tamma Phillips has maintained her weight loss and has a total cholesterol of 138.
Six months ago, Phillips learned that she has Type 2 diabetes, despite careful diet and exercise. She wasn't aware that recent studies have found longtime statin users on daily, high-dose therapy develop Type 2 more often than those who don't take the drugs.
"That concerns me," she said, "I'm definitely going to discuss it with my doctor on my next visit."
Irene Maher can be reached at email@example.com.
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What's your Risk?
What's your risk of having a heart attack in 10 years? That's a key question doctors ask when deciding who should be on a statin. You can get an idea of your own risk by answering a few health questions on heart attack risk calculators. The National Cholesterol Education Program has a quick test for laypeople that asks just seven questions. The American Heart Association's is much more indepth and includes questions most doctors would ask.
1% I took both tests, using my health history and numbers from a recent fasting blood test. In a matter of minutes I found out my risk is 1 percent, considered very low.
8% Then I entered my blood test values, but pretended they belonged to a 6-foot, 180-pound man. Those changes inched the risk up to 8 percent, still considered very low.
16% Then I made the man a smoker, and the risk jumped to 16 percent -- borderline high.
You can take the test at heart.org. Search for "heart attack risk assessment." Among the numbers you'll need to know: blood pressure, fasting glucose, and the big 3 cholesterol values.