The HDL/triglycerides trap - high density lipoprotein - interview with William Castelli, director of the Framingham Heart Study - interview

Nutrition Action Healthletter, Sept, 1990 by Bonnie Liebman

These people also develop high blood pressure and an elevated uric acid, but not more than 6 to 8 in men or 4 to 6 in women. So it's not the high uric acid that doctors treat.

Q: What about people who only have some of these risk factors?

A: If they just have the low HDL and high triglycerides, they'll still run a higher risk, but not as high. This whole syndrome is being missed in American medicine.

Q: What treatment do you recommend for these people?

A: The first step is to go on a diet and lose the spare tire. I'd give them a good six months to seriously try a good diet, even engaging a dietitian.

If they fail to bring their triglycerides under 150 and their total/HDL ratio under 4.5, I'd go to drugs. That is, unless their total cholesterol goes below 150 or their LDL cholesterol goes below 90. Then I would leave them alone.

Q: What about exercise?

A: Exercise works beautifully--it tends to raise HDL and lower LDL. And the more you exercise, the more you can eat. It makes life more interesting.

Q: Which drugs do you recommend?

A: The fibrate drugs like gemfibrozil. Not niacin, because it raises their blood sugar and uric acid even higher. Lovastatin doesn't control triglycerides and HDL as well, and the resins [like cholestyramine] frequently make them worse.

Sometimes we put people on gemfibrozil and if their LDL comes back up, we can add resins and even niacin. Studies in helsinki and Stockholm have shown that if you treat people who have low HDL and high triglycerides with drugs, you can cut their heart attack rate in half in five years.

Q: What else are doctors missing when they treat heart disease?

A: It's idiotic to say that we shouldn't measure cholesterol in the elderly. their total cholesterol isn't as good at predicting the risk of heart disease, but their total/HDL ratio is.

Let's face it. Most of us have this gut feeling that if you came through this hail of hot dogs and hamburgers that rain down on us and made it to 70 without getting a heart attack, you had some protective factor and we should leave you alone forever.

But the data show that a 70-year-old is twice as likely as a 50-year-old to have a heart attack over the next two years. This does not suggest that the old tolerate. cholesterol better. Perhaps they tolerate it worse.

Q: Do women need to worry about their cholesterol?

A: Yes. After menopause, the total,LDL, and HDL cholesterol, the total/HDL ratio, and triglycerides predict better in women than in men who's going to get a heart attack. At least a half dozen intervention triils show that cholesterol and heart attack rates fall as readily in women as in men who are put on cholesterol-lowering diets or drugs.

Q: Is there any difference between a man's and woman's risk?

A: Yes. In essencE, women don't get the disease before menopause, but after menopause, it only takes them six to ten years to catch up to ment. That's because they have smaller arteries.

The heart disease rates are the same for 60-year-old women as for 50-year-old men, and the same for 70-year-old women as for 65-year-old-men. Women and men aged 75 to 80 have identical rates, but by then there aren't many men left.