Let’s Talk About Cholesterol Emily Lundstrom, R.Ph., Pharm.D. Melissa Kalb, RD, LD August 8, 2007

Outline Discuss the different types of cholesterol Identify healthy cholesterol levels Provide an overview of medications used to treat abnormal cholesterol levels Discuss options for a low cholesterol diet

What is cholesterol? Fat-like, waxy substance Cholesterol comes from two sources The food you eat and your liver

Why do we need cholesterol? Some is needed for bodily functions To make cells and some hormones Too much cholesterol Clogs arteries Causes heart attack or stroke

Types of Cholesterol LDL Cholesterol-”Lousy” Cholesterol HDL Cholesterol-”Happy” Cholesterol Triglycerides Which is the most important? LDL HDL & Triglycerides are a close 2 nd and 3 rd

LDL—The “Lousy” Cholesterol Contributes to build up of fat deposits in arteries Decreases blood flow to the heart Want this to be low Lowered by diet, exercise, and most medications

HDL—The “Happy” Cholesterol Helps carry “bad” cholesterol away from arteries to liver The higher the better! How can you raise your HDL? Exercise Some medications help Eating properly may help

Triglycerides Most common type of fat in the body Comes mostly from diet Things that increase triglycerides

What Level of Cholesterol is good? Total cholesterol <200 Triglycerides <150 HDL—”Happy” Cholesterol >40 LDL—”Lousy” Cholesterol <100? * LDL goal depends on other health conditions or risk factors

Medications “Statins” Bile acid binders Nicotinic acid (“Niacin”) Fibric Acids Cholesterol absorption inhibitors Fish Oil

“Statins” Lipitor® (atorvastatin) Zocor® (simvastatin)* Pravachol® (pravastatin)* Crestor® (rosuvastatin) Lescol® (fluvastatin)* Mevacor® (lovastatin)* *Indicates generic available

“Statins” LDL Triglycerides HDL Well tolerated Could experience headache, constipation, stomach cramps or gas A small number of patients experience muscle pain or weakness Will require liver tests Most need to be taken before bed

Bile Acid Binders LDL Triglycerides HDL Mix powders with water, juice, or food Space from other medications Side effects: Constipation, nausea, gas Questran® (cholestyramine)* Colestid® (colestipol) Welchol® (colesevelam) *Indicates generic available

Nicotinic Acid (Niacin) HDL Triglycerides LDL Vitamin B3 May cause flushing and itching Take with food Niacor ® *, Niaspan ® *, Slo-Niacin ® * OTC *Indicates generic available

Fibric Acids Triglycerides HDL LDL Take with food Side effects: Nausea, diarrhea, constipation May cause muscle pain or weakness Lopid® (gemfibrozil)* Tricor® or Triglide® (fenofibrate) *Indicates generic available

Cholesterol Absorption Inhibitors Zetia® (ezetimibe) Stops cholesterol absorption from food Does not have to be taken with food Often combined with a “statin” LDL Side effects: headache, abdominal pain, diarrhea

Fish Oil Omacor® Rx only FDA Approved $$ Expensive $$ * Now called Lovaza® Omega-3 Supplement Over-the-counter Not FDA Approved Inexpensive Triglycerides

Two-In-One Combination medications available: Vytorin® (simvastatin + ezetimibe) Advicor® (lovastatin + Niaspan) Pravigard PAC® (pravastatin + aspirin)

References American Heart Association. Accessed at National Heart, Lung, and Blood Institute. Accessed at Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults. Executive Summary of The Third Report of The National Cholesterol Education Program (NCEP) Expert Panel on Detection, Evaluation, And Treatment of High Blood Cholesterol In Adults (Adult Treatment Panel III. JAMA. 2001; 285:

References Grundy SM, Cleeman JI, Merz CN et al. Implications of recent clinical trials for the National Cholesterol Education Program Adult Treatment Panel III guidelines. Circulation. 2004; 110:

Low Cholesterol Diet Melissa Kalb, RD, LD

Therapeutic Lifestyle Changes (TLC) Limit saturated fats and trans fats Limit cholesterol Eat more omega-3 fats Monitor total fat intake grams of fiber per day Include meat alternatives Weight loss Exercise

Saturated Fats Generally from animal or dairy sources Also from coconut and palm oils Items to limit = marbled meat, poultry skin, bacon, sausage, whole milk, cream, butter

Trans Fats Process that turns an unsaturated (healthier fat) into saturated fats Items to limit = stick margarine, shortening, some fried foods, and packaged foods made with hydrogenated oils

Cholesterol TLC goal = 200 milligrams per day American Heart Association = 300 milligrams per day Items to avoid – egg yolks, fatty meat, whole milk, cheese, shrimp, lobster, and crab.

Omega-3 Fats These fats may help to reduce your risk of heart disease Good sources = salmon, tuna, mackerel, walnuts, canola soybean and flaxseed oil.

Total fat intake 25% to 35% of total calories Including heart-healthy fats

Fiber Goal = 20 – 30 grams per day Soluble fiber – helps to lower LDL (“bad”) cholesterol Sources: oats, beans, peas, citrus fruits, strawberries, apple pulp Insoluble fiber – helps to decrease your cardiovascular risk Sources: whole wheat bread, wheat cereals, cabbage, carrots, cauliflower, apple skin

Meat Alternatives Meat and cheese can be high in saturated fats Items to try = soy burgers, and beans in casseroles

Weight Loss and Exercise Following lifestyle changes Speak with your health care team to determine an exercise plan

Healthy Lifestyle and Medication Do I need to follow a healthy lifestyle if I am taking my medication?

Questions??? Emily Lundstrom, Pharm.D. Chris Green, Pharm.D. Melissa Kalb, RD, LD