So You Have High Blood Cholesterol NATIONAL INSTITUTES OF HEALTH National Heart, Lung, and Blood Institute _______ Know Your Cholesterol Level Lowering your high blood cholesterol is an important step for reducing your chance of developing heart disease. Remember to ask your doctor for your total cholesterol, LDL-cholesterol levels each time they are measured. Write the levels down on the chart below to keep track of your progress. Date _________________________ Date _________________________ Total Cholesterol _______________ Total Cholesterol_____________ HDL-Cholesterol _______________ HDL-Cholesterol_______________ LDL-Cholesterol _______________ LDL-Cholesterol_______________ Date _________________________ Date _________________________ Total Cholesterol ______________ Total Cholesterol_____________ HDL-Cholesterol _______________ HDL-Cholesterol_______________ LDL-Cholesterol _______________ LDL-Cholesterol_______________ Date _________________________ Date _________________________ Total Cholesterol _______________ Total Cholesterol_____________ HDL-Cholesterol _______________ HDL-Cholesterol_______________ LDL-Cholesterol _______________ LDL-Cholesterol_______________ Developed and produced by: National Cholesterol Education Program NHLBI Obesity Education Initiative Endorsed by: American Heart Association ___ Table of Contents So You Have High Blood Cholesterol1 How This Booklet Can Help High Blood Cholesterol: What You Need to Know3 Cholesterol and Your Risk of Heart Disease How High Blood Cholesterol Leads to Heart Disease Good and Bad Cholesterol: The Lipoproteins What Makes Blood Cholesterol High or Low Other Risk Factors for Heart Disease What Your Blood Cholesterol Levels mean ...If You Do Not Have Heart Disease ...If You Do Have Heart Disease Questions You May Have About Your High Blood Cholesterol Improving Your Blood Cholesterol Levels: What You Need to Do18 Take Action: Heres How Three Steps to Reducing High Blood Cholesterol Levels LearnAbout the Step I and Step II Diets Make Physical Activity Work for You Lose Weight If You Are Overweight You May Need To Take Medicine Where You Can Go for Help28 Ask Your Health Professionals Get More Information Glossary So You Have High Blood Cholesterol... How This Booklet Can Help A high blood cholesterol level means that you have more cholesterol in your bloodstream than your body needs. The higher your blood cholesterol level, the greater your risk or chance of developing coronary heart diseasethe most common form of heart disease. Anyone can develop high blood cholesterol, no matter what his or her age, gender, race, or ethnic background. In fact, 52 million American adults now have a blood cholesterol level high enough to need medical advice to help lower it. High blood cholesterol has no warning signs. So, you may be surprised to learn that you have it. dont be alarmed, but do take it seriously. You can lower high blood cholesterol and bring down your risk of heart disease. This booklet can help. The first section, High Blood Cholesterol: What You Need To Know, will give you facts about cholesterol and heart disease. It will help you understand what your blood cholesterol levels mean. It also will explain heart diseases other risk factors and explain how these risk factors combine with high blood cholesterol to put you at even greater risk. The second section, Improving Your Blood Cholesterol Levels: What You Need To Do, will show you how to change your diet, become more physically active, and lose weight (if you are overweight). These steps are the best way for most people to lower their high blood cholesterol. This section also will tell you about an added step some people need: taking medicines. At the end of the booklet, you will find two other useful resources: Where You Can Go for Help, a list of people and organizations that can give you more information and support; and A glossary, which explains key medical and technical terms talking about high blood cholesterol. Lowering your high blood cholesterol is very important: If you already have heart disease, you can reduce your risk of future problems; if you dont have heart disease, you can cut your risk of ever developing it. The advice in this booklet is for adults. The booklet is part of a series on cholesterol from the National Cholesterol Education Program (NCEP). Another booklet, Step by Step: Eating To Lower Your High Blood Cholesterol, gives more detailed information about how to change your diet. The NCEP also has booklets for both children and adolescents with high blood cholesterol and their parents. Page 30 tells you where to write in order to obtain these booklets. 1 HIGH BLOOD CHOLESTEROL: WHAT YOU NEED TO KNOW Cholesterol and Your Risk of Heart Disease Cholesterol is a waxy substance that occurs naturally in all parts of the body. Your body needs cholesterol, which it uses to make many hormones and vitamin D. Cholesterol is also involved in producing bile acids, which help the body process the fats you eat. Your body produces enough cholesterol to meet its needs. How High Blood Cholesterol Leads to Heart Disease When there is too much cholesterol in your blood, the excess can become trapped in the walls of your arteries. By building up there, the cholesterol helps to cause hardening of the arteries or atherosclerosis. And atherosclerosis causes most heart attacks. How? The cholesterol buildup narrows the arteries that supply blood to the heart, slowing or even blocking the flow of blood to the heart. So, the heart gets less oxygen than it needs. This weakens the heart muscle, and chest pain (angina) may occur. If a blood clot forms in the narrowed artery, a heart attack (myocardial infarction) or even death can result. Cholesterol buildup happens very slowlyyou are not even aware of it. If you lower your high blood cholesterol level, you can slow, stop, or even reverse the buildupand lower your risk of illness or death from heart disease. "Good" and "Bad" Cholesterol: The Lipoproteins Cholesterol travels in the blood in packages called lipoproteins. Just like oil and water, cholesterol and blood do not mix. So, in order to be able to travel in the bloodstream, the cholesterol made in the liver is also coated with a layer of protein making a lipoprotein. This lipoprotein then carries the cholesterol through the bloodstream. Two types of lipoprotein affect your risk of heart disease. Low-density lipoproteins (LDLs): the bad cholesterol. LDLs carry most of the cholesterol in the blood, and the cholesterol and fat from LDLs are the main source of dangerous buildup and blockage in the arteries. Thus, the more LDL-cholesterol you have in your blood, the greater your risk of heart disease. High-density lipoproteins (HDLs): the good cholesterol. HDLs carry some of the cholesterol in the blood, but this cholesterol goes back to the liver, which leads to its removal from the body. So HDLs help keep cholesterol from building up in the walls of the arteries. If your level of good cholesterol is low, your risk of heart disease is greater. What Makes Blood Cholesterol High or Low Why do some people have too much cholesterol in their blood? Many factors help determine whether your blood cholesterol level is high or low. The following factors are the most important: Heredity: Your genes partly determine the amount of cholesterol your body makes, and high blood cholesterol can run in families. Diet: Two nutrients in the foods you eat make your blood cholesterol level go up: saturated fat, a type of fat found mostly in foods that come from animals; and cholesterol, which comes only from animal products. Saturated fat raises your cholesterol level more than anything else in the diet. Reducing the amounts of saturated fat and cholesterol you at is an important step in reducing your blood cholesterol levels. Weight. Excess weight tens to increase your blood cholesterol level. If you are overweight and have a high blood cholesterol, losing weight may help you lower it. Physical activity/exercise. Regular physical activity may help to lower LDL-cholesterol and raise HDL-cholesterol levels. Age and sex. Before menopause, women have total cholesterol levels that are lower than those of men the same age. Pregnancy raises blood cholesterol levels in many women, but blood cholesterol levels should return to normal about 20 weeks after delivery. As women and men get older, their blood cholesterol levels rise. In women, menopause often causes an increase in their LDL-cholesterol level. Some women may benefit from taking estrogen after menopause, because estrogen lowers LDLs and raises HDLs. Alcohol. Alcohol intake increases HDL-cholesterol. However, doctors dont know whether it also reduces the risk of heart disease. Drinking too much alcohol can certainly damage and liver and heart muscle and cause other health problems. Because of these risks, you should not drink alcoholic beverages to prevent heart disease. Stress. Stress over the long term has not been shown to raise blood cholesterol levels. The real problem with stress may be how it affects your habits. For example, when some people are under stress, they console themselves by eating fatty foods. The saturated fat and cholesterol in these foods probably cause higher blood cholesterol, not the stress itself. Other Risk Factors for Heart Disease In addition to a high LDL-cholesterol level and a low HDL- cholesterol level, other factors also increase your chance of heart disease. The chart below lists these risk factors. The more of them you have, the higher your chance of developing heart disease. If you have any of these risk factors in addition to your high blood cholesterol, your risk of heart disease is even greater. In addition to the risk factors on the chart, another factor that influences your risk of heart disease is where your body stores excess fat. If you have an apple-shaped body with most of your fat around the stomach, you are at a greater risk of heart _____ Risk Factors for Heart Disease Factors You Can Do Something About Cigarette smoking High blood cholesterol (high total cholesterol and high LDL-cholesterol) Low HDL-cholesterol High blood pressure Diabetes Obesity Physical inactivity Factors You Cannot Control Age: 45 years or older for men 55 years or older for women Family history of early heart disease (heart attack or sudden death): Father or brother stricken before the age of 55 Mother or sister stricken before the age of 65 ______ disease than if your body is pear-shaped, with most of your fat around your hips. Generally, men carry their fat around the stomach, while women carry it on the hips and thighs. Talk to your doctor about all of your risk factors and what you can do to reduce your chance of heart disease. Often, the actions you take to control one risk factor help reduce others as well. For example, losing weight helps to reduce your blood cholesterol levels and high blood pressure, and helps to control diabetes. Regular physical activity can help you lose weight as well as improve the fitness of your heart and lungs, which also can help lower your risk of heart disease. What Your Blood Cholesterol Levels Mean Now that you know the basics, lets take a closer look at blood cholesterol levels and their relationship to heart disease risk. Since the risks are greater for people who already have heart disease, this section is divided into two parts: The first part deals with people who dont have heart disease now. This means if you have never had any of the problems listed under Signs of Coronary Heart Disease. Go to page 9. If you have ever had any of the problems listed under Signs of Coronary Heart Disease, the second part of the booklet will help. Go to page 13. Signs of Coronary Heart Disease Have ever had a heart attack. Suffer from chest pain which has been diagnosed as angina. Have had heart surgery such as a bypass operation, balloon, or angioplasty procedure. Have ever been told by your doctor that you have a buildup or blockage in any of your arteries. What Your Blood Cholesterol Levels Mean... If You Do Not Have Heart Disease "Why Should I Worry? Ive never been sick a day in my life." Even if you dont now have any signs of heart disease, it doesn't mean you never will. Now is the best time for prevention. Otherwise, a high blood cholesterol level, as well as other risk factors, can lead to problems in the future. Your Blood Cholesterol Tests Blood cholesterol levels are measured in a small blood sample taken from your finger or your arm. The blood is tested for total cholesterol and, if accurate results can be obtained, HDL- cholesterol levels. You do not have to fast or do anything special before having this blood test. Depending on the results, you may also need a second blood test, a lipoprotein profile, to determine your LDL-cholesterol level; you do have to fast for this test. An LDL-cholesterol level gives the doctor more information about your risk of heart disease and helps to guide any necessary treatment. Check Your Level After the test, compare your results with the levels listed in the chart below. Refer to page 10 to see what you next steps should be. Classification: Total and HDL-Cholesterol* Total Cholesterol Desirable Blood Borderline-High Blood High Blood Cholesterol Cholesterol Cholesterol less than 220 mg/dL 200-239 mg/dL 240 mg/dL and above HDL-Cholesterol Low HDL-Cholesterol Less than 35 mg/dL *For anyone 20 years of age or older Your Next Steps If you Do Not Have Heart Disease If Your Total and HDL Levels are... Then... Total Cholesterol HDL-Cholesterol less than 200 mg/dL 35 mg/dL or greater You are doing well and should have your total and HDL- cholesterol levels checked again in about 5 years. In the meantime, take steps to keep your total cholesterol level down: eat foods low in saturated fat and cholesterol, maintain a healthy weight, and be physically active. The last two steps, along with not smoking, will also help keep your HDL level up. less than 200 mg/dL 200-239 mg/dL less than 35 mg/dL You will need lipoprotein profile to find out your LDL- cholesterol level. For this test you need to fast for 9-12 hours before the test. have nothing but water, or coffee or tea with no cream or sugar. 200-239 mg/dL 35 mg/dL or greater Your doctor will see if you have other risk factors for heart disease and determine whether more tests (including a lipoprotein profile to find out your LDL-cholesterol) need to be done. No matter what your sick is, it is important to eat foods low in saturated fat and cholesterol, to maintain a healthy 240 mg/dL and above any level You will need a lipoprotein profile to find out your LDL- cholesterol level. Again, you need to fast for 9-12 hours before the test, having nothing but water, or coffee or tea with no cream or sugar. What Your LDL-Cholesterol Levels Mean A high LDL-cholesterol level increases your risk for heart disease. use the chart below to find out about your risks and your next steps. Classification: LDL-Cholesterol Desirable Borderline-High Risk High Risk less than 130 mg/dL 130-159 mg/dL 160 mg/dL and above Your Next Steps If You Do Not Have Heart Disease If Your LDL Level is Then... less than 130 mg/dL You have a desirable LDL-cholesterol level. You will need to have your total and HDL-cholesterol levels tested again in 5 years. You should follow an eating plan low in saturated fat and cholesterol, maintain a healthy weight, be physically active, and not smoke. 130 mg/dL or above Your doctor will look at your other heart disease risk factors and decide what you need to do to lower your LDL-cholesterol level. The higher your level and the more other risk factors you have, the more you need to follow a diet low in saturated fat and cholesterol. For example, if your LDL is 160 mg/dL or greater and you have fewer than two other risk factors, your LDL goal is a level below 160 mg/dL. If your LDL is 130 mg/dL or greater and you have two or more other risk factors, your goal is to reduce your LDL level to below 130 mg/dL. It is also important to lose weight if you are overweight, to be physically active, and to not smoke. discuss your treatment plan with your doctor. PROFILE Jack Williams Story Risk Factors Jack is 35 years old, and his father died from a heart attack at the age of 50. Jack smokes about half a pack of cigarettes a day. His diet is high in saturated fat, cholesterol and calories. He is not physically active. His doctor ordered a lipoprotein analysis, and the results are shown below: Lab Report Total cholesterol 260 mg/dL HDL-cholesterol 40 mg/dL LDL 190 mg/dL Evaluation Jack is at a high risk for heart disease. Heres why: He has a family history of early death from heart disease. He smokes. His total cholesterol and LDL-cholesterol levels are high. He is physically inactive. What Your Blood Cholesterol Levels Mean... If You Do Have heart Disease "I already have heart diseaseisnt the damage already done?" Its not too late to help your heart. In fact, if you already have heart disease, you should pay even more attention to your cholesterol level. You have even more to gain. A person with coronary heart disease has a much greater risk of having a future heart attack than a person without heart disease. If you lower your blood cholesterol level, you can definitely reduce your risk of future heart attacks and may, in fact, prolong your life. Your Blood Cholesterol Tests Since you have heart disease, finding out your blood cholesterol level is a little different. You will need to have a blood test called a lipoprotein profile. This test will determine not only your total and HDL-cholesterol levels, but also your LDL-cholesterol leveland levels of another fatty substance called triglyceride described on page 16. In order to take the test you must fast. That means you can have nothing to eat or drink but water, or coffee or tea with no cream or sugar for 9-12 hours beforehand. Check Your Levels Since you have heart disease, your doctor will use your LDL- cholesterol level to decide on the best treatment. Your aim should be to have a LDL-cholesterol level lower than that of people who do not have heart disease. Compare your levels to those in the chart on page 14 to find out what your next steps should be. Your Next Steps If You Do Have Heart Disease If Your LDL Level is... Then... 100 mg/dL or less You do not need to take specific steps to lower your LDL, but you will need to have your level tested again in 1 year. In the meantime, you should closely follow a diet low in saturated fat and cholesterol, maintain a healthy weight, be physically active, and not smoke. greater than 100 mg/dL You need to have a complete physical examination done to see if you have a disease or a health condition that is raising your cholesterol levels. You will probably need a diet that is lower in saturated fat and cholesterol, i.e., the Step II diet (see page 21). Since this diet will be more effective, your doctor will likely encourage you to start there, as well as to be physically active, to lose weight if you are overweight, and to not smoke. If your LDL level does not come down, you may need to take medicine. PROFILE Betty Johnsons Story Risk Factors Betty is 60 years old and his a history of chest pain for which she has had tests and which her doctor diagnosed as angina. She is about 35 pounds overweight. She is not physically active. She has no family history of heart disease. Lab Report Total cholesterol 240 mg/dL HDL-cholesterol 30 mg/dL LDL-cholesterol 174 mg/dL Triglycerides 180 mg/dL Evaluation Betty has a high risk for having a heart attack. Heres why She already has coronary heart disease Her total blood cholesterol and LDL-cholesterol are high Her HDL-cholesterol is low She is overweight She is physically inactive Since Betty has established coronary heart disease and high total and LDL-cholesterol levels, the doctor decided to try the Step II diet. he asked her what she usually eats and found that her diet is high in saturated fat, cholesterol, and calories. She eats out often and likes to cook and eat big meals with her family. The doctor told her how to gradually change what she eats in order to follow a Step II diet that is also low in calories (see page 21) and how it could help her to lose weight. After talking to the doctor, Betty tried making changes in what she ate for a few days, but then she stopped, not wanting to bother with it. She did not make any changes that would reduce the saturated fat, cholesterol, and calories in her diet. Three months later Betty had a heart attack. (Betty Johnsons story continues on page 25.) Questions You May Have About Your High Blood Cholesterol Since Im a Woman, Why Should I Worry About Having a Heart Attack? Its true that before menopause, women are unlikely to die from heart disease. But as they get older, especially after menopause, their chance of developing heart disease goes up. Women and men in their seventies have an equal likelihood of dying from heart disease. Thats why at any age it is important for women as well as men to the steps to prevent high blood cholesterol. At 69, Im Feeling Fine. Why Do I Need to Make Changes Now? You have three very good reasons to change some of your health habits. First, the risk of heart disease increases as you get older. Although you are feeling well, you may already have some buildup of fat and cholesterol in your arteries. Unless you try to stop or reverse the buildup, you may have a heart attack later on. Second, adopting a healthy lifestyle helps reduce the risk of heart diseaseeven for people your age. People in their seventies can lower their blood cholesterol levels, and therefore deposit less fat in their arteries. Being more physically active is another important step that helps to protect older people against heart disease. A heart-healthy diet should also be a balanced diet. Most people will not have to make extreme changes to make their eating and activity habits healthy. These changes can fit in with your overall lifestyle. Reason number three: Youve got a lot of living yet to do. A man at 69 can expect on average to live another 15 years; a woman at 69 can expect to live another 19 years. The changes you make now can help make those years more healthy and enjoyable. Will Lowering My Blood Cholesterol Help Me Live Longer ? Many studies show that lowering cholesterol levels reduces the risk of illness or death from heart disease, which kills more men and women each year than any other illness. If you have heart disease, lowering your cholesterol level will probably help you to live longer, but you will definitely reduce your risk of illness and death from heart attack. Since Heredity Can Cause High Blood Cholesterol, Do My High Levels Mean That My Family Is At Risk? If you have high blood cholesterol, your family may also have high levels. This includes your children, parents, brothers, and sisters. They should all have their cholesterol levels tested to help protect them from heart disease. How Much Does My Cholesterol Level Change From Day To Day? Your cholesterol level varies somewhat from day to day , sometimes by more than 15-20 mg/dL. Different laboratories also may use different methods of analyzing blood cholesterol levels which can give different results. This is why you need more than one cholesterol test before starting any treatment. What Is a Cholesterol Ratio? Some laboratories may calculate a cholesterol ratio. The ratio is obtained by dividing either total cholesterol or LDL- cholesterol by the HDL-cholesterol. The ratio is not recommended since it is more important to know each value separately. Be sure to get separate total cholesterol, LDL,and HDL values. My Blood Test Showed I Also Have High Triglycerides How Does That Affect My Risk of Heart Disease? Triglycerides are a form of fat that is carried through the bloodstream. Most of your body's fat tissue is in the form of triglycerides. High blood triglyceride levels aline usually do not raise your risk of heart disease. But many people have a high triglyceride level along with high LDL- and low HDL- cholesterol levels. In these cases,the three are often treated together. NormalBorderline-HighHighVery Highless 200 mg/dL200-400 mg/dL4000-1000 mg/dLgreater than 1,000 mg/dL Borderline-high and high triglyceride levels are first treated with the same diet and lifestyle changes used for high blood cholesterol levels. These changes include : Weight loss (if you are overweight) A diet low in saturated fat and cholesterol (Step I and Step II see page 21.) Increased physical activity No smoking No alcoholic beverages (for some people) Usually "very high" levels are due to heredity. They may be lowered with the changes above with medicines. Does Eating Foods High in Salt and Sodium Increase My Blood Cholesterol Level? No. The amount of sodium in your diet has no effect on your cholesterol level. However, sodium can cause blood pressure to rise in some people. Further, many people with high blood cholesterol also have high blood pressure. If you have both, it's a good idea to reduce your sodium intake. The National High Blood Pressure Education Program recommends no more than 2,400 mg per day (the amount in about 1 teaspoon of table salt). On average, Americans take in 4,000 to 6,000 milligrams of sodium each day. This sodium comes from many different foods. Foods high in sodium include some canned soups, vegetables, and meats; instant soups and cereals; ready-to-eat cereals; salty snacks and crackers; pickles and olives; and many frozen meals. For more help on reducing sodium as part of a cholesterol- lowering diet, write for Step by Step Eating To Lower Your High Cholesterol (See page 30.) 2 Improving Your Blood Cholesterol Levels: What You Need To Do. Take Action: Here's How Now that you understand why you should lower your high blood cholesterol, this section details how to do it. It covers: Action steps to take and the benefits to expect Specific guidelines for diets to lower high blood cholesterol Practical ways to change eating habits Tips to increase your physical activity The section also describes medicines for lowering high blood cholesterol. Medicines may become necessary for those who cannot lower their blood cholesterol through diet and exercise. Three Steps to Reducing High Blood Cholesterol Levels Three steps can help you reduce your high blood cholesterol: 1. Follow the Step I or Step II diet. These diets are described in the boxes on page 21. Your doctor will first recommend one or the other. The diets contain all the daily nutrients you need and emphasize eating foods that are low in saturated fat, total fat , and cholesterol, and high in starch and fiber. You will probably be asked to follow the Step I diet first to see if it brings your blood cholesterol levels down sufficiently. If not, you may have to move to the Step II diet. If you already have coronary heart disease or a very high LDL level, your doctor may recommend starting with the Step II diet. 2. Be more physically active. 3. Lose weight if you are overweight Fortunately, these three steps work together. For example: Eating less fat, especially saturated fat, also may help you decrease the amount of cholesterol and calories you eat. Why? Foods high in fat and saturated fat are high in calories and often high in cholesterol. In fact, all fats both saturated and unsaturated fat have more than twice as many calories as either carbohydrate or protein. They provide 9 calories per gram and the other two provide 4 calories per gram. Being more physically active helps burn more calories which helps in weight loss. It may also help you lower your LDL- cholesterol and raise your HDL-cholesterol, as well as improve the health of your heart and lungs. Losing excess weight if you are overweight can help lower your LDL-cholesterol and increase your HDL-cholesterol. How Low Will You Go? By closely following your diet , being more physically active, and watching your progress with regular checkups,you can lower your blood cholesterol level. How much your cholesterol levels change depends on: How much fat, especially saturated fat, and how much cholesterol you ate before you changed your diet; How closely you follow the changes; and How your body responds to these changes. Usually the higher your blood cholesterol is to begin with, the more the levels go down. However, sometimes due to heredity, levels will not change enough no matter how well you change your habits. For example: Your total blood cholesterol level is 240 mg/dL, and you are eating a diet high in saturated fat and cholesterol. By going on the Step I diet, you could reduce your cholesterol level by 5-35 mg/dL; and 5-15 mg/dL more, if you then go on Step II. Over time, you may reduce your cholesterol level by 10-50 mg/dL or even more. This drop will slow the fatty buildup in your arteries and reduce your risk of illness and death from heart attack. In fact, studies have shown that, in adults with high blood cholesterol levels, for each 1 percent reduction in total cholesterol levels, there is a 2 percent reduction in the risk of heart attack. So if you reduce your cholesterol level by 10 percent (for example, from 240 mg/dL to 216 mg/dL), your risk of heart disease could drop by 20 percent. And many people will get even more of a drop in their cholesterol level. 1. Learn About the Step I and Step II Diets Step I Diet On the Step I diet, you should eat: 8-10 percent of the day's total calories from saturated fat. 30 percent or less of the day's total calories from fat. Less than 300 milligrams of dietary cholesterol a day. Just enough calories to achieve and maintain a healthy weight. (You may want to ask your doctor or registered dietitian what is a reasonable calorie level for you.) Step II Diet On the Step II diet, you should eat: Less than 7 percent of the day's total calories from saturated fat. 30 percent or less of the day's total calories from fat. Less than 200 milligrams of dietary cholesterol a day. Just enough calories to achieve and maintain a healthy weight. (You may want to ask your doctor or registered dietitian what is a reasonable calorie level for you.) Practical ways to change your diet Here are some tips on how to choose foods for the Step I and Step II diets. For more help, write for Step by Step: Eating To Lower Your High Blood Cholesterol (see page 30). To cut back on saturated fats, choose: Poultry, fish, and lean cuts of meat more often. Remove the skin from chicken and trim the fat from meat. Skim or 1 percent milk, instead of 2 percent or whole milk. Cheeses with no more than 3 grams of fat per ounce (these include low-fat cottage cheese or other low-fat cheeses). Cut down on full-fat processed, natural, and hard cheeses(like American, brie, and cheddar). Liquid vegetable oils that are high in unsaturated fat (these include canola, corn, olive, and safflower oil). Use tub or liquid margarines that list liquid vegetable oil as the first ingredient (instead of lard and hydrogenated vegetable shortening which are high in saturated fat). Choose products that are lowest in saturated fat on the label. Fewer commercially prepared and processed foods made with saturated or hydrogenated fats or oils (like cakes, cookies, and crackers). Read food labels to choose products low in saturated fats. Foods high in starch and fiber, instead of foods high in saturated fats. Cutting back on saturated fat helps you to control dietary cholesterol as well. Two additional points to remember when cutting back on dietary cholesterol are: Eating less organ meat (such as liver, brain, and kidney). Eat fewer egg yolks as whole eggs or in prepared foods (try substituting two eggs whites for each whole egg in recipes, or using an egg substitute). To included more foods high in starch and fiber, choose: More whole grain breads and cereals, pasta, rice, and dry peas and beans. More vegetables and fruits. 2. Make Physical Activity Work for You Regular physical activity by itself may help reduce deaths from heart disease by: lowering LDL levels raising HDL levels lowering high blood pressure lowering triglyceride levels reducing excess weight improving the fitness of your heart and lungs If you have been inactive for a long time, start with low-to- moderate level activities such as walking, taking the stairs instead of the elevator, gardening, housework, dancing, or exercising at home. Begin by doing the activity for a few minutes most days, then work up to a longer programat least 30 minutes per day, 3 or 4 days a week This can include regular aerobic activities such as brisk walking, jogging, swimming, bicycling, or playing tennis. If you have heart disease or have had a heart attack, talk with your doctor before starting an activity to be sure you are following a safe program that works for you. Otherwise you may experience chest pain or further heart damage. If you have chest pain, feel faint or light-headed, or become extremely out of breath while exercising, stop the activity at once and tell your doctor as soon as possible. PROFILE Jack Williams' Story continued from page 12 Remember- Jack is 35 years old; his father died from a heart attack at the age of 50; Jack smokes ; his diet is high in saturated fat, cholesterol , and calories; and he is not physically active. Reducing Risk The doctor identified Jack as being at a high risk for heart disease. She advised him to stop smoking. Jack had tried to stop on his own, but never quit for more than a few weeks. This time, he enrolled in a program at work that charges him for each class. But if he stops smoking, he will get his money back. His health insurance premium also will go down. The doctor wanted Jack to focus on giving up smoking. She said that changes in his eating and activity could wait. However, she told him to eat fewer fried foods and more breads, fruits, and vegetables. She said he should get at least some physical activity and suggested that he part further away when shopping at the store, work in his garden, and use the stairs more often. Two months later, Jack had quit smoking. But he still attended the smoking classes so that he wouldn't start again. The doctor said he was ready to start a Step I diet to improve his blood cholesterol levels, and she told him how to follow it. If Jack had high blood pressure, he would have been advised to follow a low-sodium Step I diet. The doctor also suggested he try to walk about 5-10 minutes in the evening after work, a few days a week. 3 months later his blood cholesterol levels were: Lab Report 3 months ago Today Total Cholesterol 260 mg/dL 224 mg/dL HDL-Cholesterol 40 mg/dL 45 mg/dL Jack's progress pleased his doctor, but his levels were still not low enough. The doctor told him to walk briskly for 10-15 minutes three times a week and to add more time each week until he reached a 30 minute walk. She also put him on a Step II diet and referred him to a registered dietitian (R.D.) to help him follow it. After 1 month on the diet, he could follow it at home but not when eating out. He went back to the dietitian to get more tips to help him follow the diet when eating out. After 3 months on the diet, Jack's blood cholesterol levels had fallen to the desirable range. His wife also liked the diet and has modified family recipes, as well as tried new ones for the whole family to enjoy. Now when Jack eats out, he asks about how a food is cooked to be sure it fits into the diet. His new food habits have become a part of his way of eating and his family's. Jack also walks 30 minutes, three or four times a week. He hasn't smoked a cigarette since joining the class at work, and he still attends the class once a month. He feels great and has lots of energy. He plans to stick to his new habits and keep his cholesterol levels down and reduce his risk of heart disease. PROFILE Betty Johnson's Story continued from page 14 Remember- Betty is 60 years old and has a history of chest pain diagnosed as angina; she is 35 pounds overweight and is not physically active; and she has no family history of heart disease. Reducing Risk After her heart attack, the doctor asked Betty whether she would follow the Step II diet or preferred to try taking medicine. Betty promised herself and the doctor to follow the Step II diet. She began to eat smaller portions; choose items lower in saturated fat and cholesterol such skim milk and low-fat dairy products instead of the full-fat varieties; and baked her foods more often using herbs and spices. Because she has heart disease, she started with a low-calorie, Step II diet. When she returned to the doctor,s office 2 months later, she had lost about 8 pounds. But her total and LDL-cholesterol levels were still too high. Lab Reports 2 months ago Today Total Cholesterol 240 mg/dL 216 mg/dL LDL-Cholesterol 30 mg/dL 37 mg/dL LDL-Cholesterol 174 mg/dL 149 mg/dL Triglycerides 180 mg/dL 150 mg/dL The doctor felt that she needed more help on her diet, so he referred her to a registered dietitian for help. He also told her to begin a morning walking program at the local mall and build up to walking 20-30 minutes, three or four times per week. In 3 months, Betty lost another 10 pounds and felt better. She was walking three times per week and following the Step II diet most of the time. She ate out less often and used the Step II guidelines in cooking for her family. (Betty Johnson's story is continued on page 26.) 3. Lose Weight If You Are Overweight Two action steps are key. Eat fewer calories (cutting back on the fat you eat will really help). Burn more calories by becoming more physically active. PROFILE Betty Johnson . . . Reaching the Goal Betty followed the Step II diet and was more physically active. Her blood values were getting close to her goals. Lab Report 5 months ago 3 months ago Today Total Cholesterol 240 mg/dL 216 mg/dL 205 mg/dL HDL-Cholesterol 30 mg/dL 37 mg/dL 40 mg/dL LDL-Cholesterol 174 mg/dL 149 mg/dL 135 mg/dL Triglycerides 180 mg/dL 150 mg/dL 150 mg/dL But, since her LDL level was still too high (greater than 130 mg/dL), the doctor decided to put her on a low dose of medicine. He explained how important it was for her to continue her new eating, exercising, and weight loss habits, even while taking the medicine. That way she could take a lower dose. Betty took the medicine, continued following the Step II diet, and exercised four times a week. Two months later, her blood cholesterol levels reached their goals. Betty is determined to keep up her good work and not to have another heart attack. You May Need To Take Medicine If you have successfully changed your eating habits for at least 6-12 months, and your LDL-cholesterol level is still too high, you may need to take medicine. Some people will need to take medicine from the start of their treatment because of a very high LDL level or the presence of heart disease. If you doctor prescribes medicine, you also will need to: Follow your cholesterol-lowering diet. Lose weight if overweight. Be more physically active. Stop smoking. Taking all these steps together may lessen the amount of medicine you need, or make the medicine work better. And that reduces your risk of heart disease. Medicines Your Doctor May Prescribe Sever types of medicine help lower blood cholesterol levels. These include: Major Drugs Bile acid sequestrants (cholestyramine and colestipol) Nicotinic acid HMG CoA reduces inhibitors ar "statins" (e.g., lovastatin, pravastatin, and simvastatin) Other Drugs Fibric acid derivatives (gemfibrozil) Probucol In addition, if you are a woman going through or past menopause, your doctor may talk with you about estrogens. Sometimes called Estrogen Replacement Therapy, this can lower blood cholesterol levels, and may make it unnecessary to take a cholesterol-lowering drug. Drugs that lower blood cholesterol work in different ways. Some may work for you while others may not. Before the doctor prescribes any medicine, be sure to state what other medicines you are taking. And once a medicine is prescribed, take it exactly the way our doctor tells you so. If you have any side effects from a medicine, tell you doctor right away. The amount or type of drug can be changed to reduce or stop unwanted side effects. Whatever medicine you take, continue to follow the Step I or Step II diet and to be more physically active. This will help keep the dose of medicine as low as possible. 3 WHERE YOU CAN GO FOR HELP As Your Health Professionals In addition to your doctor, other health professionals can help you control your blood cholesterol levels. These persons include: Registered dietitians (R.D.) or qualified nutritionists, who can explain food plans and show you how to make changes in what you eat. They can give you advice on shopping for and preparing foods, and eating out. They also can help you set goals for changing the way you eat, so you can successfully lower your high blood cholesterol without making big changes all at once in you eating habits or in your lifestyle To find a Registered Dietitian contact: The National Center for Nutrition and Dietetics' Consumer Nutrition Hotline 1-800-366-1655, Your local hospital or health department, or Your doctor. The nurse in you doctor's office, who also may be able to answer questions about hour high blood cholesterol or your diet. Lipid specialists, who are doctors with an expertise in treating high blood cholesterol and similar conditions. In special cases, you may be referred to lipid specialist if the treatment your doctor is prescribing does not successfully lower you blood cholesterol levels. Your doctor, who can answer questions about the medicines you are taking. Be sure to tell your doctor about everything you are taking and if you feel different after you take any of them. Pharmacists, who are aware of the best ways to take medicines to lessen side effects and of the latest research on drugs. Get More Information The National Cholesterol Education Program (NCEP), coordinated by the National Heart, Lung, and Blood Institute (NHLBI), has a pamphlet called Step by Step: Eating to Lower Your High Blood Cholesterol. This pamphlet gives details on how to change your eating habits in order to lower your blood cholesterol levels. The NCEP also has booklets for children with high blood cholesterol levels and their parents. In addition, the NHLBI has a booklet, Exercise and Your Heart, and a resource list of agencies and organizations able to answer questions on cholesterol and the other risk factor for hear disease. For these and other materials, write: National Cholesterol Education Program NHLBI Information Center P.O. Box 30105 Bethesda, Maryland 20824-0105 The American Heart Association can also provide you with additional information. Contact your local American Heart Association or call 1-800-AHA-USA1 (1-800-242-8721) Glossary Atherosclerosis: A type of "hardening of the arteries" in which cholesterol, fat, and other substances in the blood build up in the walls of arteries. As the process continues, the arteries to the heart may narrow, cutting down the flow of oxygen-rich blood and nutrients to the heart. Bile Acid Sequestrants: One type of cholesterol-lowering medication, including cholestyramine and colestipol. The sequestrants bind with cholesterol-containing bile acids in the intestines and remove them in bowel movements. Calories: Units of measurement that represent the amount of energy the body is able to get from foods. Different nutrients in foods provide different amounts of calories. Carbohydrates and protein provide about 4 calories per gram, while fat (bother saturated and unsaturated) yields about 9 calories per gram. Carbohydrate: One of the nutrients that supply calories to the body. Carbohydrates may be simple or complex. Complex carbohydrates also are called starch and fiber, which come from plants and can be found in whole-grain breads, cereals, pasta, rice, dried peas, and beans, corn, lima beans, fruits, and vegetables. Cholesterol: A soft, waxy substance. The body makes enough cholesterol to meet its needs. Cholesterol is used in the manufacture of hormones, bile acid, and vitamin D. It is present in all parts of the body, including the nervous system, muscle, skin, liver, intestines, and heart. Blood cholesterolCholesterol circulating in the bloodstream. It is made in the liver and absorbed from the food you eat. The blood carries it for use by all parts of the body. A high level of blood cholesterol leads to atherosclerosis and an increased risk of heart disease. Dietary cholesterolCholesterol in the food you eat. It is present only in foods of animal origin, not those of plant origin. Dietary cholesterol, like dietary saturated fat, raises blood cholesterol, which increases the risk for heart disease. Estrogen Replacement Therapy (ERT): Treatment with he hormone estrogen, which has many effects, one of which is cholesterol lowering. It includes different amounts of estrogen and progestin, two hormones produced normally by women who have menstrual periods. ERT is given only to women who have gone through menopause. ERT may help prevent heart disease by lowering blood cholesterol levels, especially LDL. Fat: One of the nutrients that supply calories to the body. The body needs only small amount of fat. Foods contain different types of fat, which have different effect on blood cholesterol levels. These include: Total fatThe sum of the saturated, monounsaturated, and polyunsaturated fats present in food. All foods have a varying mix of these three types. Saturated fatA type of fat found in greatest amounts in the skin, whole-milk dairy products, lard, and in some vegetable oils, including coconut, palm kernel, and palm oils. Saturated fat raises blood cholesterol more than anything else eaten. Unsaturated fatA type of fat that is usually liquid at refrigerator temperature. Monounsaturate fat and polyunsaturated fat are two kinds of unsaturated fat. When used in place of saturated fat, monunsaturated and polyunsaturated fats help to lower blood cholesterol levels. Monounsaturated fatAn unsaturated fat that is found in greatest amount in food from plants, including olive and canola oil. Polyunsaturated fatAn unsaturated fat found in greatest amounts in foods from plants, including safflower, sunflower, corn, and soybean oils. Fibric Acid Derivatives: One type of cholesterol-lowering drug. It includes gemfibrozil. The fibric acids lower triglycerides and raise HDLs. HMG CoA Reductase Inhibitors: See "Statins." Lipids: Fatty substances, including cholesterol and triglycerides, that are present in blood and body tissues. Lipoproteins: Protein-coated packages that carry fat and cholesterol through the bloodstream. Lipoproteins are classified according to their density. High-density lipoprotein (HDL)Lipoproteins that contain a small amount of cholesterol and carry cholesterol away from body cells and tissues to the liver for the excretion from the body. A low level of HDL increases the risk of heart disease, so the higher the HDL level, the better. HDL is sometimes called the "good" cholesterol. Low-density lipoprotein (LDL)Lipoproteins that contain most of the cholesterol in the blood. LDL, the "bad" cholesterol, carries cholesterol to the tissues of the body including the arteries. For this reason, a high level of LDL increases the risk of heart disease. Lipoprotein Profile: A test that uses blood from the arm to measure your total, HDL-, and LDL-cholesterol, and triglyceride levels. The test requires a fast for 9-12 hours beforehand. Nothing can be consumed but water, or coffee or tea with no cream or sugar. Milligram (mg): A unit of weight equal to one-thousandth of a gram. There are about 28,350 mg in 1 ounce. Dietary cholesterol is measured in milligrams. Milligrams/Deciliter (mg/dL): The measure used to express cholesterol and triglyceride levels in the blood. It stands for the weight of cholesterol in milligrams in a deciliter of blood. A deciliter is one-tenth of a liter or about one-tenth of a quart. Nicontinic Acid: A cholesterol-lowering medicine that reduces total and LDL-cholesterol and triglyceride levels and also raises HDL-cholesterol levels. This is the same substance as Niacin or vitamin B1, but in doses that lower cholesterol, it should only be used with your doctor's supervision. Risk Factor: A habit, trait, or condition in a person that is associated with an increased chance (or risk) for a disease. Statins: One type of cholesterol-lowering drug that includes lovastatin, pravastatin, and simvastatin. These drugs lower LDL levels by limiting the amount of cholesterol the body can make. Triglycerides: Lipids carried through the bloodstream to tissues. Most of the body's fat tissue is in the form of triglycerides, stored for use as energy. Triglycerides are obtained primarily from fat in foods. DISCRIMINATION PROHIBITED: Under provisions of applicable public laws enacted by Congress since 1964, no person shall, on the grounds of race, color, national origin, handicap or age, be excluded from participation in, be denied the benefits of, or be subjected to discrimination under any program or activity (or on the basis of sex, with respect to any education program or activity) receiving Federal financial assistance. In addition, Executive Order 11141 prohibits discrimination on the basis of age by contractors and subcontractors in the performance of Federal contracts and Executive Order 11246 states that no federally funded contractor may discriminate against any employee or applicant for employment because of race, color, religion, sex, or national origin. Programs of the National Heart, Lung, and Blood Institute are operated in compliance with these laws and Executive Orders. U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES Public Health Service National Institutes of Health National Heart, Lung, and Blood Institute NIH Publication No. 93-2922 Revised December 1993