Disorders that are characterized by arteriosclerosis include diabetes, insulin resistance, hypertension, a diet too high in refined carbohydrates and too low in antioxidants, decreased thyroid hormone, and a genetic tendency toward producing too much homocysteine.
How Do You Know If Your Vessels Are Healthy?
Only rarely will a doctor be able to diagnose arteriosclerosis from hearing an odd sound (known as a bruit) in the carotid artery, or from hearing a click or abnormal rhythm in the heart. If you have diabetes or high blood pressure, are significantly overweight, never exercise, follow a poor diet, or are a smoker, I can virtually guarantee that you already have arteriosclerosis.
Most of the time, arteriosclerosis is not diagnosed until an individual has a cardiac event of some kind, such as a stroke or heart attack. Individuals with chest pain or difficulty walking because of vascular insufficiency often undergo an X-ray test known as an angiogram, which visualizes blood vessels that are injected with dye. Sometimes an ultrasound technology known as a Doppler device will be used to diagnose vessels that are blocked.
The good news is that arteriosclerosis can be largely prevented or reversed by diet and lifestyle factors. In fact, the famous Nurses’ Health Study, which has followed more than 84,000 women for over fourteen years, has demonstrated that the risk of arteriosclerosis is very low in those women who exercise regularly, abstain from smoking, and follow the kind of diet I recommend in chapter 7.20 I’ll discuss selected risk factors in more detail below. It’s important for every perimenopausal woman to get a complete checkup from a health care provider who is qualified to evaluate her cardiovascular status. This evaluation should include, as a minimum, a thorough history and physical exam, EKG, blood pressure check, and lipid profile.
FACTORS ASSOCIATED WITH AN INCREASED RISK FOR CARDIOVASCULAR DISEASE
~ You are/were a habitual smoker.
~ You have a strong family history of heart disease (especially before the age of sixty).
~ You have high LDL (“bad”) cholesterol (greater than 130 mg/dl).
~ Your HDL (“good”) cholesterol is low (less than 46 mg/dl).
~ You have high triglycerides (greater than 150 mg/dl).
~ You have high blood pressure (greater than 130/85).
~ You have high levels of the amino acid homocysteine in your bloodstream.
~ You are overfat (body mass index greater than 25) with an apple-shaped figure (a preponderance of body fat above the level of the hips).
~ Your waist measures 33.5 inches or more.
~ You have a hypertrigliceridemic-waist phenotype—for women, that means a waist circumference of 85 cm (about 33.5 inches) or more and a triglyceride level of 1.5 mmol/L (about 133 mg/dl) or more.21
~ You have periodontal disease.
~ You have diabetes.
~ You are sedentary and don’t exercise.
~ You have a history of significant clinical depression.
Cholesterol
A lipid profile is a measure of your total cholesterol, LDL cholesterol, HDL cholesterol, and triglyceride levels. Here are the numbers to shoot for on the lipid profile.
TOTAL CHOLESTEROL: Below 200. (Note: If your cholesterol is slightly higher than 200, don’t worry about it if your HDL is sufficiently high.)
HDL (HIGH-DENSITY LIPOPROTEIN): HDL—the “good” cholesterol—should be 45 or higher; 67 or above is ideal. Low HDL cholesterol has been shown to be a more potent risk factor in women than it is in men. Women with low levels of this cholesterol subtype (a reading of 35 or less) have a sevenfold increase in heart disease risk compared to those whose HDL levels are normal.22 Low HDL is one of the first indicators of insulin resistance.
LDL (LOW-DENSITY LIPOPROTEIN): LDL—the “bad” cholesterol—should be 130 or below. LDL cholesterol rises after menopause in many women, a fact that was the basis for promoting estrogen replacement, which decreases LDL levels. If your LDL is greater than 150 mg/dl (some doctors use even lower numbers), you’re considered at high risk for coronary artery disease. LDL cholesterol undergoes free-radical damage and forms plaques in the arteries.
TRIGLYCERIDES: This number should be 150 or lower. Triglycerides are an independent risk factor for women. An ideal triglyceride level for a woman is around 75. A woman with a triglyceride level of greater than 200 has a 14 percent risk of developing coronary artery disease. High triglycerides are associated with toxic abdominal fat and glycemic stress in part because the liver, as well as other areas of the body, stores excess blood sugar as triglycerides.
RELATIONSHIP OF TOTAL CHOLESTEROL TO HDL: Neither type of cholesterol is inherently bad or good. Both are necessary for good health. They need to be balanced in the body. Divide your total cholesterol by your HDL cholesterol. If the resulting number is 4 or less, you are at low risk, regardless what your total cholesterol number is. The ratio of total cholesterol to HDL is a much better predictor of risk than simply your total cholesterol number. Ask your doctor to give you a copy of your lipid profile so that you can get to know your numbers. It’s very motivating to watch your lipid profile improve every year when you commit to becoming healthier than ever before at midlife.
Currently 40 percent of women older than fifty-five have elevated cholesterol levels.23 Though interpretation of lipid profile results will vary from lab to lab, a total cholesterol level as high as 225 to 240 does not necessarily indicate that a woman is at increased risk for heart disease if her HDL cholesterol is also high (45 or above). Because most of the studies of heart disease and blood lipid levels have been done on men, we still don’t know exactly what levels of blood lipids are optimal for women. What we do know is that women can have higher total cholesterol levels than men and not be at increased risk for heart disease.
Get the lipid profile repeated at least every five years if it’s normal. If your blood sugar is high, get the test repeated more frequently.
If your cholesterol levels are high, know that dietary change and a good supplement program can lower cholesterol significantly and quickly. Though there are a number of ways to do this, I’m partial to the RESET Program from USANA (see THE RESET PROGRAM) or The Belly Fat Cure (Hay House, 2009) by Jorge Cruise. Oftentimes the positive changes that occur with changes in lifestyles are so motivating that they spur permanent lifestyle changes that not only result in healthy cholesterol levels, but also prevent adult onset diabetes and a host of other chronic degenerative diseases. Permanent fat loss is a most rewarding benefit as well.
If you cannot or will not institute lifestyle improvements, at least take omega-3 supplements and make sure your vitamin D levels are optimal (see What to Do When You Can’t Get Enough Sunlight).
REFINING CARDIOVASCULAR RISK FACTORS
The newest research shows that a few additional numbers can be very important for assessing risk. According to cardiologist Michael Ozner, M.D., medical director for the Cardiovascular Prevention Institute of South Florida, traditional testing that measures only LDL, HDL, and triglycerides uncovers only 40 percent of people at risk for heart attacks. Also checking blood levels of C-reactive protein (an inflammatory marker), apolipoprotein B (apoB, the number of LDL particles in the blood), and lipoprotein (a) (LP(a), a type of small, dense LDL that is more dangerous than other cholesterol-carrying particles) can boost that figure to 90 percent because these tests catch people who are at risk even though they have normal levels of LDL. (For further information, read Dr. Ozner’s book The Great American Heart Hoax: Lifesaving Advice Your Doctor Should Tell You About Heart Disease Prevention (But Probably Never Will) [BenBella Books, 2008] or visit his website at www.DrOzner.com.) An alternative way to test for the number of LDL particles in the blood that is gaining much attention is to test for the level of LDL-P using nuclear magnetic resonance (NMR).
These new tests have been determined to be so important for assessing risk that the updated American Diabetes Association and American College of Cardiology expert consensus guidelines for treating cardiometabolic pati
ents now call for measuring levels of apoB as well as non-HDL cholesterol (total cholesterol minus HDL cholesterol).24 For those with highest risk (those with known cardiovascular disease or those with diabetes plus at least one additional risk factor for cardiovascular disease), treatment goals are a non-HDL cholesterol level of less than 100 mg/dl, an apoB level of less than 80 mg/dl, and an LDL-P level of less than 1,000 mg/dl. For those considered to be high risk (which includes diabetics with no other risk factors for cardiovascular disease as well as those who have not been diagnosed with cardiovascular disease or with diabetes but who have two major risk factors for cardiovascular disease), the treatment goals are a non-HDL cholesterol level of less than 130 mg/dl, an apoB level of less than 90 mg/dl, and an LDL-P level of less than 1,300 mg/dl.
Not all doctors order such detailed blood analysis, and not all labs do them. One lab that does is Berkeley HeartLab, which also offers a free, cutting-edge service I’ve tried myself called the 4myheart Program. Once your doctor orders a blood test from Berkeley, the lab evaluates the results along with your particular environmental, genetic, and lifestyle risk factors to design a personalized plan covering recommendations on nutrition, exercise, stress management, and medication. Berkeley’s clinical educators (who include RNs, registered dieticians, exercise physiologists, and other health care professionals who have experience working with cardiovascular patients) then provide support in person, by phone, or online to help patients follow their recommended lifestyle modifications. (For more information, call 800-432-7889 or visit www.bhlinc.com.)
What About Statins?
I am very concerned about the overuse of statin drugs, such as Lipitor, Crestor, and Zocor, among others, which are being prescribed to millions of women in the belief that because they lower LDL cholesterol levels, they will prevent heart disease. Adding more fuel to the fire recently were the results of a large, long-term, double-blind, placebo-controlled, randomized clinical trial called the Justification for the Use of Statins in Primary Prevention: An Intervention Trial Evaluating Rosuvastatin (JUPITER). Published in 2009, JUPITER looked at the effect of a statin called rosuvastatin (sold as Crestor) on 17,802 healthy men and women with normal LDL cholesterol levels but elevated C-reactive protein (CRP) levels, a sign of inflammation. The study was halted after just two years by an independent review panel that saw that the placebo group was having more heart attacks, strokes, angina, and death from cardiovascular disease. Data showed that those taking Crestor reduced their risk of heart attack by 54 percent and their risk of stroke by 48 percent—and the risk of dying from all causes by 20 percent.25
Despite this evidence, I still feel strongly that prescribing statins to healthy women to prevent heart disease misses the mark because it’s the same line of seriously flawed reasoning that led doctors to prescribe Premarin to millions of women back in the 1980s and ’90s because it was shown to raise HDL (good cholesterol) levels. The high LDL cholesterol that statins are prescribed to reduce is not a disease, and lowering levels won’t prevent disease—as already mentioned, half of all people who get heart disease don’t even have high cholesterol! The cause of heart disease is cellular inflammation and arterial wall damage, which oxidizes LDL and causes it to stick to damaged blood vessel walls and build up plaque. This is what JUPITER showed us—when you reduce inflammation, heart disease risk drops. The researchers happened to be focusing on statins as the means of reducing LDL, but statins are not without serious side effects and risks. (For example, JUPITER also showed that more people taking Crestor developed diabetes than did those on placebo.) Further, because the study was halted prematurely, long-term safety data on taking Crestor were not gathered. Yet there are perfectly safe and very effective ways to lower LDL that don’t involve taking statins, such as proper diet, exercise, stress reduction, and supplementation with the right nutrients. That is where I think we ought to be putting the attention.
Note: The level of LDL cholesterol that is considered “normal” has been continually reduced over the years, largely because of the behind-the-scenes influence of the pharmaceutical industry, which supplies the majority of research grants to academic medicine. The American Heart Association’s 2004 recommendations for “normal” LDL for people with very high risk for cardiovascular disease were lowered to 70 mg/dl, which I consider ridiculous.26 (The rest of the guidelines range from a recommended LDL level of under 100 for those with high risk to below 160 for those with low risk.) I believe that if your cholesterol level is lower than 240–275 mg/dl and your HDL is 60 or above, you don’t need a statin.
Here’s what all women should know about statins: despite all the hype, JUPITER included, many large studies involving statins have failed to show much benefit. Here’s a partial list.
~ The ALLHAT clinical trial (announced in 2002) was the largest study in the world using Lipitor.27 Ten thousand participants with high LDL cholesterol were treated either with statins or lifestyle changes. Though the subjects in the group that took Lipitor did, in fact, lower their LDL cholesterol significantly compared to the control group, there was no difference in death rate from heart attack between the two groups!
~ The Heart Protection study supposedly conferred “massive” benefits to participants who took Zocor for five years compared to controls who didn’t take the drug.28 After five years, those on the drug had an 87.1 percent survival rate compared to an 85.4 percent survival rate for those who didn’t. But the survival rates were independent of the lowering of cholesterol, so there was no difference between the two groups in reduction of death from heart disease.
~ The Japanese Lipid Intervention Trial of 2002 was a six-year study of 47,294 patients treated with Zocor. The drug lowered LDL cholesterol dramatically in some participants and moderately or not at all in others. After five years, there was no correlation between LDL cholesterol levels and death rate.29
~ A 2003 meta-analysis of forty-four clinical trials involving 9,500 patients found that the death rate for those taking statins was identical to those taking no drugs. More worrisome is that 65 percent of those taking statins experienced adverse side effects that caused many to withdraw from the study. The bottom line: statin drugs showed no benefit in reducing the overall number of deaths.30
~ The 2003 ASCOT-LLA (Anglo-Scandinavian Cardiac Outcomes Trial—Lipid Lowering Arm) study compared the benefits of Lipitor versus placebo in patients with normal LDL cholesterol but with high blood pressure and other risk factors for heart disease.31 After three years, Lipitor was credited with decreasing the risk of heart attack and stroke. But no reduction in deaths occurred. And there were actually more deaths in the women taking Lipitor than in those who didn’t take it!
~ The 2003 University of British Columbia Therapeutics Initiative Study found that statin drugs did not prevent heart disease in women.32
~ A Canadian study on the effectiveness of different countries’ guidelines for statin treatment showed that to prevent one cardiac death, 154 people who had been recommended statins would have to take them for five years. To prevent one cardiac death among people with low risk for heart disease (who had not been recommended these drugs), 23,000 patients would have to take statins for the same length of time.33
WOMEN AND STATINS
Just as heart disease can have different symptoms in women than in men, statins affect women differently than they do men. Looking at total mortality figures in major clinical trials, it’s clear that the risk-benefit balance of statins is less favorable in women than it is in men.34 Plenty of evidence now exists to show that low cholesterol, especially in women older than fifty, is associated with higher levels of cancer and early death. For example, a meta-analysis of thirteen studies published in the Journal of the American Medical Association showed that for women who do not have cardiovascular disease, lipid lowering does not lower mortality. For women who have been diagnosed with cardiovascular disease, statins were shown to reduce coronary heart disease events and deaths from heart disease, but they did not redu
ce total mortality.35
A prospective study from Austria comparing cholesterol levels and health outcomes for more than 80,000 women and 67,000 men over a fifteen-year period found that high cholesterol in women over age fifty was not a predictor of cardiovascular problems or stroke (although it was for women under age 50). The study found that low cholesterol levels in people older than fifty was associated with higher death rates from cancer, liver disease, and mental illness.36 Another prospective study from Italy of 3,120 women age sixty-five and older who were followed for twelve years found no health benefits from having low LDL levels. For most of the subjects, elevated LDL was associated with greater longevity and fewer cardiac events.37
Statin Drugs Deplete Vital Nutrients
If statins were wildly effective in decreasing the mortality rate from cardiovascular disease, then their benefits might outweigh their risks. But this is clearly not the case. And the risks, though vastly underreported, are considerable. The serious side effects resulting from statins are the result of how they work. Statin drugs block cholesterol production in the body by inhibiting an enzyme called HMG-Co-A reductase. This is the same pathway that the body uses to create coenzyme Q10 and substances called dilochols, both of which are absolutely essential for proper cell health. By blocking cholesterol production, statins also block production of these vital nutrients.
The Wisdom of Menopause Page 71
