Archive for cholesterol

Extreme Lipids II

Posted in Diabetes, Heart Disease with tags , , , , , on September 23, 2008 by Dr. CJ

There aren’t many lipid panels that stun me, which is probably a bad sign – that we are becoming more tolerant of slothen behavior and excessive hyperlipidemia, knowing that there are medications to rescue one from years of lousy self-care.

This gentleman had a most impressive lipid panel, perhaps forcing you to ask how he is even alive.

Total Cholesterol    1248  (normal < 200)

LDL                         n/a  (normal < 130)

– invalid when Triglycerides > 300

HDL                        n/a  (normal >39)

– invalid when Triglycerides > 1200

Triglycerides          8062  (normal <150)

This very nice 40-something gentleman presented to me in clinic in DKA (Diabetes KetoAcidosis) – his first doctor visit in 10+ years.  He was continually thirsty (polydipsia), continually urinating large amounts (polyuria), and had lost 40 pounds over the past 3 months . . . unintentionally.

He knew that he had Diabetes Mellitus, for he had witnessed the disease in nearly all of his family members and recognized these classic symptoms.  Unfortunately, he waited to the point that he developed DKA. 

DKA is a complicated process – briefly, the body is so overwhelmed with high glucose in the bloodstream that it is no longer able to utilize glucose in the tissues (muscle, brain, etc.) and the pancreas is exhausted from pumping out so much insulin that it stops doing so.  The result is that the body cannot utilize glucose as a fuel source and must resort to breaking down fat (hence the weight loss) to provide fuel for the tissues.  This process creates a toxic acidic environment in the bloodstream, potentially deadly.

I admitted him to the hospital, and we achieved control over his diabetes.  It appears that he does, in fact, have Type 2 Diabetes Mellitus (DM) – formerly known as Adult-Onset Diabetes Mellitus.  DKA is far more common in Type 1 DM, but occasionally does occur in Type 2 DM.

But, about those lipids . . . there a couple notable findings:

  • the person who drew his blood immediately noticed how fatty the blood appeared
  • he had Xanthomas (cholesterol deposits) on his elbows
  • the in-house glucose machine misread his glucose as normal (the true serum test drawn at the same time was markedly elevated)
  • he had no problems with his pancreas – he dodged a bullet.  When the triglycerides are above 500, one is at risk for pancreatitis.  At 8000, it’s a miracle he didn’t kill off his pancreas (or maybe he did, and that’s why he’s not making insulin – regardless he didn’t have any lab evidence of pancreatitis)

  The quickest and easiest treatment for such severe hyperlipidemia and hypertriglyceridemia in a person with diabetes is correction of the diabetes.  I’m anxiously looking forward to rechecking those numbers, now that he is on a treatment regimen.  I’ll post an update.

Extreme Lipids I

Posted in Heart Disease, Preventive Medicine with tags , , , , , on September 22, 2008 by Dr. CJ

I saw a woman a few months ago who had concerns about a strange sensation in her chest.  She had had her cholesterol panel checked a few months prior by her gynecologist at her yearly female exam.  The gynecologist communicated to her that her total cholesterol was too high at 240 and that she should follow-up with my clinic.

Sure, 240 is high for a total cholesterol is high, but the details of the individual lipid measurements are far more telling than a “total”.  This woman’s lipid panel is a perfect case in point.

  Here’s the panel – refer to this post for details on the significance of each value.

Total Cholesterol    240  (normal < 200)

LDL                         111  (normal < 130)

HDL                        117  (normal >39)

Triglycerides            61  (normal <150)

So what?  This panel achieves one of my fantasy goals for cholesterol numbers – an HDL greater than the LDL [without cholesterol medication].  There was one other patient who came close.

Her total cholesterol is high in part due to the very high HDL cholesterol, but if you’re going to have a high total cholesterol, this is the way to do it.

Why is a high HDL a good thing?  HDL protects the heart and brain by it’s “scavenger” effects on plaque in blood vessels.

That’s no easy task, although favorable genetics certainly help.  The hightest HDL’s I’ve seen are generally in alcoholics – unfortunately, the HDL-raising benefits of alcohol are outweighted by its deleterious effects.

The best way to raise the HDL is through regular, intense exercise.  There was a study from years ago that analyzed HDL’s in runners: the more miles they ran in a week, the higher their HDL.

My old lipid panel – pre-transformation

Posted in Preventive Medicine, Transformation with tags , on February 28, 2008 by Dr. CJ

Back in May, 2006, I last had some blood work done, for an insurance exam, that included a lipid panel. I, of course, held onto those results, because I obsess over my risk factors for heart disease. Here they are, in their unimpressive glory.

  • Total Cholesterol – – – 197 [<200]
  • HDL-C – – – – – – – – – – – 34 [>39]
  • LDL-C (calculated) – – 140 [<130]
  • Triglycerides – – – – – -113 [<150]
  • TC/HDL ratio – – – – – – 5.8 [<5.0]

And, of course, as part of metabolic syndrome, one must be concerned about the fasting glucose . . .

  • Fasting glucose – – – – – 71 [<100]

My HDL had actually been worse a few years before that, in large part due to some bad habits learned in college and carried into med school.

Stay tuned for the current lipid panel results. We’ll see how much progress I was able to make since cleaning up my diet and starting an exercise regimen.  I’m nowhere near my fitness goal, but I’m hoping to see some progress.

Off to my physical exam

Posted in Preventive Medicine with tags , , on February 27, 2008 by Dr. CJ

You’ve probably heard the saying about how healthcare personnel (doctors/nurses, etc.) are the worst patients – rarely seek attention, rarely do the preventative exams that they encourage to patients, ignore advice when given to them.

It’s true . . . to some extent. I’ve encountered hundreds of much worse layperson patients, but there is some truth to that saying.

Well, I’ve decided to make use of the ol’ insurance coverage by scheduling a physical exam, really just to get my cholesterol rechecked. My “bad” (LDL) cholesterol has always been borderline okay, but my “good” (HDL) has definitely been low.
Now that I’ve busted my butt on diet and exercise, I’m expecting to see a significant improvement in both my HDL and LDL cholesterols. I’m expecting that all my lipid values will be in range now, including the TC/HDL ratio.

We’ll see if my advice to myself was any good.

I’m hungry . . . I always eat breakfast.

Another interesting article on doctors and their family members as patients.

What do my cholesterol numbers (lipids) mean?

Posted in Heart Disease, Preventive Medicine with tags , on February 2, 2008 by Dr. CJ

Of all the potential lab work that could be performed as a screening tool for certain ailments, the only one universally recommended for otherwise healthy individuals is cholesterol screening.

The most aggressive recommendation for cholesterol screening comes from National Cholesterol Education Program (NCEP III) guidelines, recommending lipid screening every 5 years for all persons over the age of 20.

According to the United States Preventive Services Task Force (USPSTF) statement in 2001, routine screening for cholesterol should begin at age 35 regardless of health, after age 20 if any risk factors for heart disease exist.

I tend to follow the NCEP III guidelines for a couple reasons: 1) a disturbing percentage of people are overweight and/or relatively inactive, 2) many people are not aware of their family history (e.g. whether or not their parents have high cholesterol), 3) abnormal numbers give me something better to stand on to encourage lifestyle changes, and 4) I want to emphasize the importance of knowing these numbers and doing something about them.

Below is a brief summary of the normal ranges of each component of a typical “lipid profile”, what behaviors tend to make them abnormal, and what you can do to improve them.

Total Cholesterol [normal < 200 mg/dL]

  • not as important as the ratio of total cholesterol/HDL

LDL [ normal < 130 mg/dL for normal-risk individuals]

  • the “bad” cholesterol
  • increased by poor diet, inactivity
  • lowered by dietary changes (esp. eating oatmeal) and physical activity
  • medication: statins

HDL [normal > 39 mg/dL]

  • the “good” cholesterol
  • lowered by inactivity, poor diet
  • elevated by regular physical activity – the more intense, the higher the HDL
  • elevated by alcohol intake (but, only beneficial in moderation; beyond that, it’s other effects negate the benefit of HDL-raising
  • medication: niacin, some effect from statins

Triglycerides [normal < 150 mg/dL]

  • “fatty acids”
  • increased by poor diet
  • lowered by diet, exercise
  • medication: fibrates, statins

TC/HDL ratio [normal < 5.0]

  • increased by a) low HDL or b) high total cholesterol
  • see above under individual components

Obesity/Inactivity – you should run, because you can’t hide

Posted in Obesity with tags , , , , , on January 23, 2008 by Dr. CJ

An obese 50-something gentleman (BMI 32, in fact) I saw yesterday in clinic said to me, “You look crisp today.” 

I wasn’t sure how to take that initially; I thought the shaved head must have impressed him.  “Yeah, you like it?  Low maintenance,” while rubbing my head.

“You look like you just got back from vacation . . . alert, a little spring in the step.”

“Nope, I wish . . . I worked out this morning, though.  That felt good.”

“Ehh, I don’t care for that.” He went on to reiterate his absolute disinterest in getting back into shape. 

       Funny thing is I bet he can’t even remember the last time he did any exercise for the sake of health, rather than for work, home projects, etc.  I’m not surprised that he doesn’t associate exercise with feeling good.  Unfortunately, this scenario is all too common – I wish this guy was the exception, but I continue to be amazed at the number of obese middle-aged individuals I encounter . . . and even moreso at their apathy regarding their health. 

      Yes, it is hard work to get fit.  It’s harder work to recover from the health problems that are bound to strike this typical individual.  This guy is a former smoker (kudos to him for quitting) but his cholesterol panel is awful (Triglycerides over 230 and HDL 24 – somehow has a normal LDL).  I’ll discuss these in detail later, but for quick reference, Triglycerides should be less than 150, HDL should be greater than 39.  The low HDL tells me he is very inactive. 

It’s satisfying (in one sense) when a patient’s labs give such an insight into his/her lifestyle.  Now, if he’ll ever take me up on my advice . . .

Is simvastatin still a good drug?

Posted in Heart Disease with tags , , , on January 22, 2008 by Dr. CJ

There was a report released recently about simvastatin being less effective than one of the more experienced statins at reducing certain measures of cardiovascular risk, despite its ability to lower the LDL cholesterol (the “bad” cholesterol) levels. 

My first word of caution regarding this: the study was performed in a very select group of individuals, people with a genetic disorder contributing to markedly elevated cholesterol levels that affects less than 1% of the population.  Right off the bat, you would be hard-pressed to apply the results of this study to the larger population (not sure why they even bothered).

It very well may not be as effective at reducing cardiac risk as we once thought, but until there is a more clear answer it shouldn’t be shunned quite yet.  As a generic drug, it is cheap and most often quite effective at lowering the LDL.  I expect there will be more detailed outcome studies comparing simvastatin with other statins.