Cholesterol and Triglycerides


Few topics have received more attention in recent years than cholesterol. Cholesterol is a naturally occurring and very necessary compound in the body. Indeed, dietary consumption of cholesterol accounts for a relatively small, albeit significant, portion of the total cholesterol detected in blood tests. While cholesterol has gotten a lot of bad press, it is essential in forming hormones, healthy skin and hair, and nerve fibers. (I used to joke “the whole world has gone "nuts" since we started watching cholesterol” – now, I’m not so sure it is a joke). The problem is that elevated fatty compounds have been associated with premature cardiovascular disease including myocardial infarction, stroke, kidney failure, and peripheral vascular disease. This correlation has led to aggressive efforts to lower cholesterol with a combination of diet, exercise, and medications.

When you receive your lab results, there are typically several numbers you should note. The first is the “total cholesterol.” When doctors first started making recommendations about cholesterol in the 1970’s, it was generally accepted that anything under 240 was good. A few years later, this was revised to 220, then 200, then 180, and now the goal is total cholesterol of less than 150. Some zealots want it under 135. I personally think this is taking things a little far, and I am happy with a total cholesterol of 200 in my patients if the distribution of the subgroups is reasonable and other risk factors are minimal.

Common subgroups of cholesterol include the “good “ cholesterol known as HDL (high density lipid), and the “bad” cholesterols known as LDL (low density lipid) and VLDL (very low density lipid). There are other subtypes, as well, and these may take on increasing clinical relevance in months to come. Suffice it to say that current recommendations call for LDL levels below 100 since elevated LDL levels are a strong indicator of cardiovascular risk. On the other hand, the higher the HDL as a percentage of the total, the better. Even if the total cholesterol stays the same, one can gain a more favorable lipid profile from regular aerobic exercise which tends to increase HDL while decreasing LDL.

The other common fatty acid group consists of triglycerides. It is a fair question to ask why you seldom hear about treating high triglycerides on the television ads. The simple truth is that there aren’t any really good medications for this condition. I am cynical enough to believe that when a really good treatment (read “new pill to sell”) is developed, there will be a media blitz about this “new” problem. This is not to suggest there is no currently recommended treatment, but the results are too inconsistent to warrant enthusiasm. In contrast to cholesterol, which is relatively stable and takes several weeks to change substantially, triglycerides can fluctuate dramatically with variation in diet from day to day. Triglycerides, like cholesterol, are considered risk factors for cardiovascular disease, but they also have the dubious distinction of being associated with pancreatitis when present in very high levels. Triglycerides are also associated with other metabolic problems such as diabetes mellitus.

My advice to patients is to eat a common sense diet, work to maintain an ideal body weight, avoid unnecessary fatty foods, and participate in a regular aerobic exercise program. If this is insufficient to control lipids, then medication is appropriate. The medications we use to treat elevated lipids include niacin (probably our safest medication, but it is not the “strongest” medication, and the burning and flushing which often occurs can be problematic), Lopid (an older medication which probably is more helpful with triglycerides than cholesterol), the statins (Lipitor, Mevacor, etc), and newer products blocking initial absorption of lipids form the G-I tract. All of these have unique advantages, all have potential problems, and, of course, most are expensive. The statins have been associated with musculoskeletal pain and malaise. Virtually all of these medications require periodic blood work to monitor liver enzymes. Consult your doctor for the best treatment for your particular situation. 

Another important factor to consider is that we are concerned with the long-term consequences of elevated lipids. Your cardiac risk can be reduced, and there is every reason to believe some regression of cardiovascular disease can occur with vigorous treatment, but it takes time. If someone has a myocardial infarction related to high lipids, it is the result of years of deterioration – nobody ever had a heart attack because their cholesterol “jumped up” to 300 one day and precipitated the event. This is truly a lifestyle issue requiring consistency over many years to see the benefit. Also, remember that this is only one of several risk factors including smoking, obesity, diabetes mellitus, and family history. It is unwise, perhaps even futile, to concentrate on the lipids without also addressing the others.

My opinion,

Thomas L. Horton, MD