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Risk of high cholesterol
Abnormal levels of fats circulating in the bloodstream, especially high cholesterol, can lead to long-term problems. The risk of having atherosclerosis and coronary artery or carotid artery disease (and therefore the risk of having a heart attack or stroke) increases as a person's total cholesterol level increases. Low cholesterol levels are therefore generally better than high cholesterol levels, although extremely low cholesterol levels may not be healthy either. A normal cholesterol level is probably 140 to 200 milligrams of cholesterol per deciliter of blood (mg/dL). The risk of a heart attack more than doubles when the total cholesterol level approaches 300 mg/dL. Getting a cholesterol test every 3 years after age 45 is a good idea, particularly for those who are overweight or have a history of heart disease. There is no proof at this time that lowering cholesterol levels through the use of statin drugs makes a person live longer.

Different types of Cholesterol - the good, the bad, and the ugly?
Not all cholesterol increases the risk of heart disease or atherosclerosis. The cholesterol carried by LDL (the so-called bad cholesterol) increases the risk; the cholesterol carried by HDL (the so-called good cholesterol) lowers the risk and is beneficial. Ideally, LDL cholesterol levels should be below 120 mg/dL, and HDL cholesterol levels should be above 50 mg/dL. The HDL cholesterol level should account for more than 25 percent of the total cholesterol. The total cholesterol level may be less important as a risk factor for heart disease or strokes than the total cholesterol to HDL cholesterol ratio. Whether high levels of triglycerides increase the risk of heart disease or strokes is uncertain. Blood levels of triglycerides above 250 mg/dL are considered abnormal, but high levels don't appear to uniformly increase the risk of atherosclerosis or coronary artery disease.

Low Cholesterol Diet
Diet can reduce cholesterol, more of an influence than may doctors realize. A diet rich in fatty fish may protect the heart and blood vessels by reducing inflammation, according to researchers. The investigators found that individuals with the highest cell levels of docosahexaenoic acid (DHA), a type of omega-3 fatty acid found in fish such as salmon and mackerel, had lower levels of C-reactive protein in their blood. C-reactive protein (CRP), a marker of blood vessel inflammation, is associated with risk of heart disease. In a study of nearly 28,000 women, levels CRP were more accurate than levels of "bad" cholesterol at predicting the risk of heart attack and other cardiovascular problems. see diet for info on the best foods to eat.
     Bulking up the diet with soy, plant sterols, vegetables, almonds, and legumes such as beans and peas and other high fiber sources can lower cholesterol and the risk of heart disease (see cholesterol study below). Incorporate more cholesterol lowering foods in your daily diet.

Exercise and Cholesterol
Being physically fit boosts levels of "good" HDL cholesterol and improves the removal of "bad" forms of cholesterol. Exercise can reduce cholesterol and levels of CRP - c reactive protein.

Eating frequency and Cholesterol
A person's cholesterol levels may depend not only on what he or she eats, but also how often, according to UK researchers. They found that middle-aged and older adults who ate frequently throughout the day had lower "bad" cholesterol levels compared with those who tended to down one or two large meals per day. This was despite the fact that the frequent eaters, on average, had a higher calorie and fat intake.

High Cholesterol Medication
Without a doubt, statin drugs do lower cholesterol levels and possibly reduce the rate of heart attacks. But do they also reduce mortality? In a new trial the statin pravastatin (Pravachol) did not reduce the risk of death and heart disease in people with moderately high cholesterol and high blood pressure.

Plant Sterols and Cholesterol
Plant sterols, structurally similar to cholesterol, have been shown to lower both total and LDL cholesterol in the body in therapeutic amounts. Even the FDA and the National Cholesterol Education Panel recommend phytosterols in the diet.

Coffee and Cholesterol
Decaffeinated coffee may raise the risk of cardiovascular disease more than regular coffee does, Atlanta investigators claim at the American Heart Association's Scientific Sessions 2005. Dr. H. Robert Superko, and colleagues at the Fuqua Heart Center and the Piedmont-Mercer Center for Health and Learning, analyzed the effects of caffeinated and decaffeinated coffee consumption on cardiovascular risk factors in 187 subjects enrolled in a clinical trial known as the Coffee and Lipoprotein Metabolism Study. The subjects were randomly assigned to one of three groups: noncoffee drinkers, coffee drinkers and decaf drinkers, who drank three to six cups a day for two months. At the end of the study period, no significant differences were found in fasting glucose or insulin (measures used to diagnosis diabetes), total cholesterol, HDL2 (the very good cholesterol) or triglycerides among the three groups. However, decaf coffee increased free fatty acid levels, which in turn led to an increase in apolipoprotein B, which is associated with LDL cholesterol. On the other hand, caffeinated coffee but not decaf, increased blood pressure. Subjects in the study drank between three and six cups a day.

Statins and cholesterol
Side effects of statins include damage to muscle tissue, harm to kidneys, elevated liver function tests, depletion of CoQ10, and slight damage to brain cells leading to mild impairment of mental function. My impression is that statins are being overprescribed (see cholesterol research update below). There is no proof at this time that lowering cholesterol levels through the use of statin drugs improves overall mortality.

BAYCOL- cerivastatin - pulled off market in Aug 2001 for rhabdomyolisis (excessive muscle breakdown) and deaths
CRESTOR-- rosuvastatin -- causes more muscle and kidney damage than the other statins. AstraZeneca's cholesterol-lowering drug Crestor has more than twice the side effects of rival statin drugs, including deaths. Adverse effects include muscle damage known as rhabdomyolysis; proteinuria or protein in the urine; nephropathy, a reduced ability of the kidneys to filter toxins from the blood; and kidney failure.
LESCOL- fluvastatin
LIPITOR- atorvastatin - The popular cholesterol-reducing drug Lipitor made by Pfizer does not prevent obstruction of the heart valve that leads to the aorta, the body's largest artery, according to June 2005 findings published in The New England Journal of Medicine. In a study conducted to determine whether the cholesterol drug, also known by its generic name atorvastatin, did more than just reduce cholesterol, doctors found that Lipitor failed to prevent obstructions that can keep the heart from pumping blood adequately. The condition, known as calcified aortic stenosis, occurs when a key heart valve narrows or becomes blocked, preventing the heart from pumping blood properly and can manifest itself in spite of reductions of cholesterol levels.
MEVACOR- lovastatin
PRAVACHOL- pravastatin
ZOCOR- simvastatin is made by Merck

Taking certain cholesterol-lowering drugs at the same time as grapefruit juice can increase the risk of potentially life-threatening muscle toxicity. The risk was greatest with Merck & Co Inc's Zocor, or simvastatin, which went on sale without prescription in Britain, and Pfizer Inc's Lipitor. The problem occurs because grapefruit contains a chemical that inactivates a liver enzyme involved in drug metabolism. As a result, regular consumption of grapefruit juice can lead to excessively high levels of medicine in the blood. The risk of serious muscle problems also increases when these cholesterol pills, or statins, are taken along with some other drugs, including HIV protease inhibitors

The cholesterol-lowering drugs statins do not appear to lower the risk of dementia or Alzheimer's disease, except possibly in cases of early-onset Alzheimer's disease. This runs counter to recent reports indicating that statins do, in fact, reduce the risk of dementia and Alzheimer's disease.

Today’s top-selling statins could be risky when taken with other drugs called fibrates by older people with diabetes. Fibrates alone can be dangerous. These drugs lower triglycerides and often are taken by diabetics.

Statin drugs, such as Lipitor or Zocor, widely used for lowering cholesterol, may slightly impair brain function and perhaps harm brain cells. Doctors have known for quite some time that these drugs cause muscle tissue damage and lower CoQ10 levels in the blood. How statins interfere with optimal brain function is not clear, but my best guess is due to interference with cholesterol metabolism. Cholesterol is involved in the formation of pregnenolone and other hormones in the brain. These hormones are crucial for memory. There's still so much we don't know about the long term risks of statins. I only recommend their use in cases of very high cholesterol levels where natural remedies have failed. Besides, even though lowering cholesterol is important, too much emphasis has been placed on cholesterol reduction as opposed to reducing the whole inflammatory process that leads to clogging of vessels with plaques.

Doctors should use "good" (HDL) cholesterol levels to determine which elderly patients are most likely to benefit from statin therapy. Statin therapy is probably indicated if the HDL level falls below 45 mg/dL or if the ratio between "bad" (LDL) cholesterol and HDL is greater than 3.3. With higher HDL levels, little benefit is achieved with statin therapy.

Cholesterol and Cancer
High blood levels of iron coupled with high levels of very low density (VLDL) lipoprotein cholesterol appear to interact to increase the risk of cancer. Iron and lipids combine to create oxidative stress, and oxidative stress has a role in the development of cancer.
     Men with high cholesterol levels, particularly if they were detected before the age of 50, may have an increased risk of developing prostate cancer

Cholesterol and Mental Function
The build-up of cholesterol plaques in arteries, a common occurrence with aging, contributes to the reduced thinking ability and dementia seen in many elderly individuals. To improve mental function, see memory.

Soy and Cholesterol
Two servings a day of soy protein -- such as that found in tofu, soy milk or soy powder -- can lower cholesterol levels as long as the raw soy is uncooked. Soy-fortified muffins, cereals or nutritional bars in which the soy protein was baked at high temperatures do not provide the benefit. An 8 percent drop in low-density lipoprotein, the so-called bad cholesterol that can lead to heart disease, can be gained from eating uncooked soy protein in the form of two 12-ounce (340 ml) servings of soy milk daily or two 2-ounce (57 grams) servings of tofu. Cooking the tofu does not destroy the key proteins because they have been stabilized. The health benefit also is found in such products as soy nuts, soy powder sprinkled on food or in milkshakes, or edamame, a raw or parboiled edible form of soybeans popular in Japan.

Measuring Skin Cholesterol
Measuring the content of cholesterol in skin tissue is a noninvasive way to assess the thickness of the carotid artery wall. The skin cholesterol test involves applying a special solution to a small area of the palm for one minute. The area is then blotted dry and an indicator solution applied, which turns blue. The hue depends on the cholesterol level, and can be accurately measured with a probe connected to a computer.

Achilles Tendon Pain and Cholesterol deposits
A painful Achilles tendon could be a sign of an inherited tendency to have high cholesterol, which carries a high risk of early heart disease. Wider recognition of the link between Achilles tendon pain and so-called "heterozygous familial hypercholesterolemia" -- or HeFH -- could lead to earlier diagnosis of this disorder. HeFH is the most common genetic disorder in Europe and the USA affecting 1 in 500 people. It is due to a mutation of a gene controlling removal of cholesterol from the blood circulation. Levels of cholesterol are doubled from birth and untreated it leads to coronary heart disease early in life. One feature of untreated HeFH is that cholesterol is deposited not only in the arteries but also at certain sites in tendons. This may lead to swelling and painful inflammation of the Achilles tendon.

Cholesterol Research Update
Effect of combined supplementation of fish oil with garlic pearls on the serum lipid profile in hypercholesterolemic subjects.
Indian Heart J. 2005 Jul-Aug;57(4):327-31.
Department of Home Science, Women's Christian College, Chennai
Elevated total cholesterol, especially low-density lipoprotein has been documented as the leading risk factor for the coronary artery disease among Indians. Studies with fish oil supplementation alone have shown an increase in low-density lipoprotein, thereby enhancing the risk associated with incidence of coronary artery disease in hypercholesterolemic subjects. In view of this, the effect of a combined supplementation of fish oil with garlic pearls on the serum lipid profile of subjects with high cholesterol was studied. We administered 600 mg of fish oil with 500 mg of garlic pearls (garlic oil) per day to 16 subjects with high cholesterol (age range: 30-60 years) with a total cholesterol above 220 mg/dl for 60 days. The effect of this combined supplementation was compared with that of a control group without any supplementation. Significant reductions were seen in all the lipid parameters (except high-density lipoprotein which was increased) in the test group after 60 days compared to that of the control group. The total cholesterol, low-density lipoprotein, serum triglyceride, very low-density lipoprotein, and the total cholesterol: high-density lipoprotein ratio reduced by 20%, 21%, 37%, 36.7%, and 23.4%, respectively, and the high-density lipoprotein increased by 5.1% after 60 days of supplementation. CONCLUSIONS: The co-administration of garlic pearls with fish oil was found to be more effective than placebo in the management of dyslipidemia.

Direct comparison of a dietary portfolio of cholesterol-lowering foods with a statin in hypercholesterolemic participants 1,2,3
American Journal of Clinical Nutrition, Vol. 81, No. 2, 380-387, February 2005
 3-Hydroxy-3-methyl-glutaryl-coenzyme A (HMG-CoA) reductase inhibitors reduce cholesterol and are increasingly advocated in primary prevention to achieve reductions in LDL cholesterol. Newer dietary approaches combining cholesterol-lowering foods may offer another option, but these approaches have not been compared directly with statins in the same persons.
Objective: The objective was to compare, in the same subjects, the cholesterol-lowering potential of a dietary portfolio with that of a statin. Design: Thirty-four hyperlipidemic participants underwent all three 1-mo treatments in random order as outpatients: a very-low-saturated-fat diet (control diet), the same diet plus 20 mg lovastatin (statin diet), and a diet high in plant sterols (1.0 g/1000 kcal), soy-protein foods (including soy milks and soy burgers, 21.4 g/1000 kcal), almonds (14 g/1000 kcal), and viscous fibers from oats, barley, psyllium, and the vegetables okra and eggplant (10 g/1000 kcal) (portfolio diets). Fasting blood samples were obtained at 0, 2, and 4 wk.
Results: LDL-cholesterol concentrations decreased by 8%, 33%, and 29% after 4 wk of the control, statin, and portfolio diets, respectively. Although the absolute difference between the statin and the portfolio treatments was significant at 4 wk (P = 0.013), 9 participants (26%) achieved their lowest LDL-cholesterol concentrations with the portfolio diet. Moreover, the statin and the portfolio diets did not differ significantly in their ability to reduce LDL cholesterol below the 3.4-mmol/L primary prevention cutoff. CONCLUSIONS: Dietary combinations may not differ in potency from first-generation statins in achieving current lipid goals for primary prevention. They may, therefore, bridge the treatment gap between current therapeutic diets and newer statins.

We hear plenty about the dangers of high cholesterol levels, but low cholesterol levels apparently confer their own risks. Naturally low cholesterol levels are associated with poorer performance on a variety of cognitive measures.

Statin use may slightly impair brain function
The results of a new study suggest that treatment with a cholesterol -lowering statin called simvastatin (Zocor) may have small negative effects on brain function. The effects on cognitive function were "too small" to have any immediate implications for the way the statin is prescribed, but they do suggest the possibility that the drug may harm the brain, says lead researcher Dr. Matthew F. Muldoon, from the University of Pittsburgh. This is the second trial the group has conducted in which a statin used for cholesterol reduction has been found to have subtle, adverse effects on cognitive function. The first study involved a drug called lovastatin (Mevacor). In the current trial, 308 adults with high cholesterol were assigned to daily treatment with a placebo, 10 milligrams (mg) simvastatin, or 40 mg simvastatin. The subjects underwent a number of cognitive function tests before the six-month treatment period started and after it ended. Compared with placebo, simvastatin was associated with minor negative changes in performance on several tests assessing attention, memory, and overall mental efficiency. In the team's earlier trial, 20 mg of lovastatin given every day for six months produced similar changes on these same tests. SOURCE: American Journal of Medicine, December 1, 2004.

A diet rich in fiber and vegetables can lower cholesterol just as much as taking a statin drug. People who cannot tolerate statin drugs because of side effects can try the diet, which the volunteers easily followed. David Jenkins of St. Michael's Hospital and the University of Toronto and colleagues created what they called a diet "portfolio" high in soy protein, almonds, and cereal fiber as well as plant sterols -- plant-based compounds used in cholesterol-lowering margarines, salad dressing and other products. They tested their diet on 34 overweight men and women, comparing it with a low-fat diet and with a normal diet plus a generic statin drug lovastatin. Each volunteer followed each regimen for one month, with a break in between each treatment cycle. Writing in the American Journal of Clinical Nutrition, Jenkins and colleagues said the low-fat diet lowered LDL -- the low-density lipoprotein or "bad" cholesterol -- by 8.5 percent after a month. Statins lowered LDL by 33 percent and the "portfolio" diet lowered LDL by nearly 30 percent. The portfolio was rich in soy milk, soy burgers, almonds, oats, barley, psyllium seeds, okra and eggplant. The Almond Board of California helped fund the study, as did several food makers and the Canadian Natural Sciences and Engineering Research Council of Canada.

Consumer advocates backed by some prominent doctors and researchers have questioned a new U.S. policy recommending wider use of statin drugs to lower cholesterol. The new cholesterol guidelines, published in July, 2004, suggest that people without high cholesterol levels should take statin drugs to get their levels even lower. The National Institutes of Health and the National Cholesterol Education Program panel that issued the guidelines cited several studies showing that people who used statins greatly lowered their risk of heart disease. But the Center for Science in the Public Interest disputed the interpretation of the studies and accused the panel members of having been influenced by their connections to drug companies. "There is strong evidence to suggest that an objective, independent reevaluation of the scientific evidence from the five new studies of statin therapy would lead to different conclusions than those presented by the current NCEP," reads the CSPI letter, signed by 35 cardiologists, nutritionists and other health professionals. "The studies cited do not demonstrate that statins benefit women of any age or men over 70 who do not already have heart disease," said John Abramson, a clinical instructor in primary care at Harvard Medical School, who signed the letter. "Furthermore, we are concerned about the findings from one of the five cited studies showing that statin therapy significantly increases the risk of cancer in the elderly."

People with metabolic syndrome -- a cluster of conditions that can include problems with weight, blood pressure, cholesterol, and blood sugar control -- are much more likely to die from heart disease and other causes than those without the syndrome.

An antioxidant found in blueberries and grapes appears to lower cholesterol as effectively as a commercial drug. A blueberry compound, called pterostilbene, activates a cellular structure that helps lower cholesterol -- the same mode of action as the cholesterol-lowering drug ciprofibrate, sold under the name Lipanor.

People with the eating disorder anorexia nervosa are more likely to attempt suicide if their cholesterol levels are low,. For several years, numerous studies have identified a link between low cholesterol and risk of suicide. However, it's far from clear if there's a cause and effect.  Conceivably, low cholesterol might lower brain chemicals that affect mood, but on the other hand depression might cause a drop in cholesterol. Or, perhaps a third irregularity results in a drop in both cholesterol and mood-related hormones. Dr. Sahelian says: Perhaps low cholesterol levels decrease levels of pregnenolone and other hormones in the brain leading to low mood.

Atorvastatin decreases the CoQ10 level in the blood of patients at risk for cardiovascular disease and stroke.
Rundek T. olumbia University College of Physicians & Surgeons, New York, NY
Arch Neurol. 2004 Jun;61(6):889-92.
Statins are widely used for the treatment of high blood cholesterol levels and coronary heart disease and for the prevention of stroke. There have been various adverse effects, most commonly affecting muscle and ranging from myalgia to rhabdomyolysis. These adverse effects may be due to a coenzyme Q(10) (CoQ10) deficiency because inhibition of cholesterol biosynthesis also inhibits the synthesis of CoQ10. To measure CoQ10 levels in blood from in those with high cholesterol levels before and after exposure to atorvastatin calcium, 80 mg/d, for 14 and 30 days. We examined a cohort of 34 subjects eligible for statin treatment according to National Cholesterol Education Program. RESULTS: The mean +/- SD blood concentration of CoQ10 was 1.26 micro g/mL at baseline, and decreased to 0.62 micro g/mL after 30 days of atorvastatin therapy. A significant decrease was already detectable after 14 days of treatment. CONCLUSIONS: Even brief exposure to atorvastatin causes a marked decrease in blood CoQ10 concentration. Widespread inhibition of CoQ10 synthesis could explain the most commonly reported adverse effects of statins, especially exercise intolerance, myalgia, and myoglobinuria.

The National Cholesterol Education Program is advising doctors to consider more intensive treatment options for people at high and moderately high risk for a heart attack. These options include setting lower treatment goals for LDL ("bad") cholesterol and initiating cholesterol-lowering therapy at lower LDL thresholds. The update is based on a review of five relatively recent clinical trials of statin therapy that show a direct relationship between lower LDL cholesterol levels and reduced risk for heart attacks and death. The LDL goal for patients at very high risk has been lowered from less than 100 to less than 70.

Psyllium
An article published in the American Journal of Clinical Nutrition reports that supplementing the diet with psyllium fiber has positive effects on blood lipids, can reduce cholesterol, while potentially cardiovascular risk. Sixty-eight adults with high cholesterol consumed a high-fiber and a control diet for 1 month each in a randomized crossover study. The high-fiber diet included 4 servings per day of foods containing psyllium that delivered 8 g per day of soluble fiber than did similar, unsupplemented foods in the control diet. Fasting blood samples and blood pressure readings were obtained at baseline and weeks 2 and 4, and the subjects' weight was monitored weekly. Compared with the control diet, the high-fiber diet reduced total cholesterol levels. Applying the Framingham cardiovascular disease risk equation to the data confirmed a reduction in risk of 4 percent. Small reductions in blood pressure were found after both diets. The subjects reported no significant differences in palatability or gastrointestinal symptoms between the diets.
        Dr. Sahelian says: Even though the reduction of cholesterol was small, it was nevertheless a positive response. Adding psyllium to the diet, for instance about a teaspoon in a glass of water two or three times a day with meals will help reduce cholesterol and also helps regulate bowel movements.