How does the American Heart Association justify 200 mg?

[Spiral]

Jeff,

I have noticed that the American Heart Association recommends that people try to get their total cholesterol levels below 200 mg/dL. But I have also read in literature from Dr. McDougall, Dr. Ornish and Dr. Esselstyn that about 35 percent of heart attacks are suffered by people with cholesterol levels between 150 mg/dL and 200 md/dL.

This leads me to two questions. One is how can the American Heart Association justify making less than 200 mg/dL the goal when it leaves people still at risk for a heart attack?

Another question is how much of a reduction of risk do we get when we drop our total serum cholesterol number from, say, 180 mg/dL to 140 mg/dL. Is there any way to get an approxiamate number?

I went to the American Heart Association's "Know Your Risk" website. But it seems their computations do not show a lower risk for heart attack once you get your cholesterol lower than 160 mg/dL.

I found this one study on the subject, but the cutoff is at 180 mg/dL. http://jama.ama-assn.org/content/300/11/1343.short

Thanks.

[JeffN]

[quote="Spiral"] One is how can the American Heart Association justify making less than 200 mg/dL the goal when it leaves people still at risk for a heart attack? [/quote]

You can never eliminate risk 100%. For the typical American, getting their cholesterol below 200, removes a significant percentage of their risk.

[quote="Spiral"] OneAnother question is how much of a reduction of risk do we get when we drop our total serum cholesterol number from, say, 180 mg/dL to 140 mg/dL. Is there any way to get an approxiamate number? [/quote]

Quoting off the top of my head today, if i remember correctly, the risk for someone with a cholesterol between 180-200 is still around 20%."

"As levels rise above 180 mg/dl, the risk for developing coronary heart disease increases. A cholesterol value of 220 mg/dl correlates to nearly a two-fold elevation in incidence of coronary heart disease as compared to 180 mg/dl. A reduction of 1% is shown to reduce the risk for coronary artery disease by 2% for levels over 200 mg/dl."

Also, in regard to the often quoted 150 as the ideal, this is not true. While it may reduce your risk to the lowers level we know, it does not guarantee you are free from risk.

There have been heart attacks in people with cholesterol under 150 even in the famous Framingham trial, which is often used as a example to defend the 150 level. I talked to Dr Castelli about this and at the time (early 1990's), he told me there had been 5 heart attacks in those with cholesterol under 150, of which, 3 they could account for but not the other two. Remember, there are very few people in the general population with cholesterols under 150 to begin with.

There are many risk factors that have been identified and these numbers and recommendations are based on population statistics and while they help us set guidelines, they do not directly identify disease nor do they apply 100% to any one individual, nor should we look at them in this way. What we can do is look at them and the more risk factors we meet, the better are "odds" are of being disease free, but it is no guarantee.

In Health
Jeff

[Spiral]

Also, in regard to the often quoted 150 as the ideal, this is not true. While it may reduce your risk to the lowers level we know, it does not guarantee you are free from risk.

There have been heart attacks in people with cholesterol under 150 even in the famous Framingham trial, which is often used as a example to defend the 150 level. I talked to Dr Castelli about this and at the time (early 1990's), he told me there had been 5 heart attacks in those with cholesterol under 150, of which, 3 they could account for but not the other two.

Jeff,
it seems that you don't believe that there is any such thing as an ideal cholesterol level. You do not believe that there is any serum cholesterol level, no matter how low, that should be considered 100 percent protective against heart attacks. However you do believe that, as a general rule, lower is better when it comes to total serum cholesterol.

Is that right?

I found your comment about the Framingham Study a little bit confusing because of the following that appears in Dr. Caldwell's Esselstyn Jr.'s book "Prevent and Reverse Heart Disease."

Perhaps the most important was the Framingham Heart Study, the fifty-year project - run the National Heart, Lung and Blood Institute, Boston University, and other academic collaboraters - that has collected and analyzed medical data from several generations of residents of Framingham, Massachusetts. Dr. William Castelli, former director of the study, put it quite baldly: over all the those years, no one in Framingham who maintained a cholesterol level lower than 150 mg/dL has had a heart attack.

I am a little confused. How does this match up with what you have understood in terms of the Framingham data?

[JeffN]

it seems that you don't believe that there is any such thing as an ideal cholesterol level.

It is not about belief but about statistics.

What I am saying is that statistically speaking, there are levels that are known to have lower risks associated with them. However, the word "ideal" is never used in statistics and these numbers are all based on statistical analysis of risk factors.

You do not believe that there is any serum cholesterol level, no matter how low, that should be considered 100 percent protective against heart attacks.

Correct. Cholesterol is only one risk factor anyway.

I mean, do you think if someone had multiple other risk factors but a cholesterol of 150, they were 100% protected?

However you do believe that, as a general rule, lower is better when it comes to total serum cholesterol.

There is some merit to risk factor analysis and I think the more risk factors we have inline, the better. And for cholesterol, yes, less is better.

How does this match up with what you have understood in terms of the Framingham data?

I am sharing with you what Dr Castelli said to me in a personal conversation at a Medical Conference, where we spend the day together, in the early 1990's

In Health
Jeff

[JeffN]

A recent interview with Dr Castelli.

http://www.prescription2000.com/Intervi ... cript.html

In it, he confirms two of my comments above that I was questioned on..

1) The statement that there was never a heart attack in anyone whose cholesterol was under 150 in Framingham is not true as there was 6 (5 at the time I spoke to him)

2) that none of these numbers can guarantee anyone anything 100% as they are only risk factor analysis.

Enjoy

In Health
Jeff

[Spiral]

Jeff,

Thanks. I beat you to it though. I posted/linked to that Catelli interview a few hours before you over at the Lounge. It's a great intereview.

He actually goes into the percent risk for heart attack in 26 years by cholesterol level. 20 out of 100 for those with 150 to 200; 90 out of 100 for those with over 300.

It did sound like for those with cholesterol levels below 150 the percentage was very, very tiny. And he seemed to imply that between 100 and 130 it was just impossible to create enough plaque to get a heart attack.

At least that's how I might interpret was Dr. Castelli said.

[JeffN]

He actually goes into the percent risk for heart attack in 26 years by cholesterol level. 20 out of 100 for those with 150 to 200;

Yup! Thats the 20% I mentioned above.

did sound like for those with cholesterol levels below 150 the percentage was very, very tiny.

And he seemed to imply that between 100 and 130 it was just impossible to create enough plaque to get a heart attack.

Agreed. But that was not the question I was asked above but it was the response I gave.

The question I was asked was...

Jeff,
it seems that you don't believe that there is any such thing as an ideal cholesterol level. You do not believe that there is any serum cholesterol level, no matter how low, that should be considered 100 percent protective against heart attacks. However you do believe that, as a general rule, lower is better when it comes to total serum cholesterol.

Is that right?

My response was...

It is not about belief but about statistics.

What I am saying is that statistically speaking, there are levels that are known to have lower risks associated with them. However, the word "ideal" is never used in statistics and these numbers are all based on statistical analysis of risk factors.

In the interview, Dr Castelli's response is

Nothing is ever 100%.

Now, for the record, "99%" and "impossible" are not the same thing especially when applied to a large population. If there was 100,000 people, I wouldn't want to be the one to tell the 1%, which is 1000 people, that their "risk" was "impossible".

Now, apply the 1% to the US Population, which is over 300 million. It may be statistically small, or maybe even statistically insignificant, in regard to statistics but it is not impossible and maybe you can understand now why we have to understand statistics and risk factors to better understand these discussions, comments and the results of studies.

At least that's how I might interpret was Dr. Castelli said.

This is why those of us who are acting in a professional role of educating the public must be careful how we interpret information and present it as we can see how misinformation can be spread innocently even by those who are well meaning & have good intentions.

Personally I would hate to be one of the 1000 who had been told it was impossible, though I have had them as patients and there seems to be a few of them around these days

In health,
Jeff

[Mayhem]

Jeff, thanks for all this information. I learned a lot here.

[JeffN]

A little "more" from my FB comments on this earlier today..

Here is more for you ....

We have to remember that any of these numbers (chol, ldl, body weight, etc etc) are what we call risk factors and the goals that we set for them are based on studies on large populations and only show statistic...al significance in relation to the population studies. Statistical significance is never 100% guarantee in anything, ever.

So, in other words, if we study a population of 200,000 people, and we organize them by cholesterol levels, (<150, 150-180, 180-220, 220-250, >250), we may find that there is a relationship between the higher the cholesterol and the greater risk for heart disease. And we may find that there were very few, if any, heart attacks in those with cholesterols under 150. However, if never means there was none in those with cholesterol under 150 and it doesn't mean that everyone in the other groups have none. It only shows the trends and the odds. In addition, it is only one risk factor being analyzed out of many. We know that BMI, smoking, weight, LDL, TG's, Blood Glucose, etc along with other factors like fiber, saturated fat, cholesterol, activity levels, etc, are all other risk factors that also matter.

So, to some how say that a cholesterol of 150 makes you completely immune to a heart attack is not completely accurate, which Dr Essy knows

In addition, by saying so, we end up with two situations.

1) all those who have cholesterol under 150, yet do not have a healthy lifestyle or a low risk profile for all the other factors and have higher odds of having a heart attack.

2) all those who have cholesterol over 150 who have the healthiest lifestyle and have very low odds of having heart disease.

In our community it has turned the 150 into some sort of Gold Standard and many walked around with it (falsely) as a badge of honor, and others as a sign of failure, which, again, was wrong, and did much harm in regard to their perspective.

Another issue that is not addressed by this numbers is how the number is achieved. Does achieving the number through drugs and/or supplements equal the same low level of risk as if it is achieved through diet? If we modify the diet in an unhealthy way to change numbers do these changes equal the same protection as if someone ate a healthier diet and had different numbers? For instance, we know we can raise HDL through adding lots of fat, or wine, but would doing so be better than having an ideal diet with a lower HDL?

All of these numbers are only risk factors and do not directly measure the disease so can never make the guarantee that people attribute to them. Yes, in most cases, we see patterns and they do matter. And, in most cases, the more of these risk factors you have inline, the better. So, if we were to identify 12 risk factors, having just one, is no guarantee of anything. Having 10 out of 12 would be better and having 12 out of 12, would give you the lowest risk profile but again, not a 100% guarantee. So, that is why they are what we call "odds ratio's" and "risk factor analysis."

[Spiral]

Jeff,

Thank you so much for digging into the details of this issue of what lipid number mean and the limits of their value. This is very helpful, I think.

I admit that I am a numbers oriented person. I have a tendency to focus on numbers.

But you mentioned on another thread (can't remember which one) that more important the lipid numbers resulting from a blood test is the "plate test."

So, even though I would like to believe that my latest lipid numbers (total choleterol = 126, LDL = 65) make me incapable of suffering a heart attack, I know that it is not that simple. I must keep the focus on what I eat and, to some extent, exercise and stress management.

I do think that the American Heart Association and other groups like it should not say that below 200 total cholesterol is desirable, nor do I think that the AHA should say that a total cholesterol between 200 and 240 is borderline.

I think the data that Dr. Castelli provided in that interview should be available to people who go to the AHA web site. Why conceal this information from the people? Why give them a false sense of security telling them that a 190 total cholesterol means that they are okay when they probably have more changes that they should make?

[JeffN]

In my DVD, From Oil to Nuts, I tell the story on what happened & why we never got (or get) this info.

I am on the road and when have time will tell the story here.

In health
Jeff

[JeffN]

This weekend, I spent some time discussing this with Dr Esselstyn, who, himself made the same points about the 150 number during the Q & A at the program we were both speaking at.

He mentioned an example of the Tarahumara Indians, who have been described in the literature as follows...

"Particularly notable was the virtual absence of the hypertension, obesity, and the usual age rise of the serum cholesterol in adults. Thus, the customary diet of the Tarahumaras is adequate in all nutrients, is hypolipidemic, and is presumably antiatherogenic."

The plasma lipids, lipoproteins, and diet of the Tarahumara indians of Mexico. The American Journal of Clinical Nutrition 31: JULY 1978, pp. 1131-1142.

So, I dug up the old article, which I have quoted here before and use in my presentations, to look closer at the data and this is what I found.

From the article...

In regard to Total Cholesterol:

"Of the adults 26% had plasma cholesterol concentrations between 150 and 180 mg/dl, and 8% had levels of 100 mg/dl and below."

In regard to Triglycerides:

"Of the adults, excluding pregnant and lactating women, 26% had levels above 150 mg/dl,and 6% had levels in excess of 200 mg/dl."

In Regard to LDL:

The exact break down was not detailed as above but instead they showed a graph of the numbers. To help see the levels, I added grid lines at 130, 100 and at 70 which are considered the "target" levels with 100 being considered, "Optimal LDL cholesterol, corresponding to lower, but not zero, rates for symptomatic cardiovascular disease events" and 70 being considered "Optimal LDL cholesterol, corresponding to lower rates of progression, promoted as a target option for those known to clearly have advanced symptomatic cardiovascular disease." I also added in the grid lines for the cutoff points of 150, 180 and 200 for cholesterol.


Based on this chart, it seems that out of about 57 adults, about 15 of them (~26%) had levels of 100 or above and about 24 of them (~42%) had levels of 70 or above with 2 of them being over 130.

LDL vs Total Cholesterol


Total Cholesterol Distribution


In addition, the average HDL was 25.

Yet, heart disease was rare.

Numbers are only markers of disease and not the disease itself.

The best test is still the "plate test."

From an earlier discussion...

But what is more important and what I feel to be the most important test, is what I call the "plate test." Very few people know about it yet it is one of the most effective tests and simple and easy to do and very inexpensive. You can even do it at home.

Here is how you do it.

When you sit down to eat each meal, look at your "plate" and see if it passes this "test", the "Plate Test."

Are at least 95% of the calories on your plate coming from unrefined unprocessed fruits, vegetables, starchy vegetables, intact whole grains and/or legumes? Are there at least 12-15 grams of fiber coming from whole natural foods? Does it meet my guidelines for sodium? Are any "exceptions" being kept to less than 5% of calories?

If your meal passes this "Plate Test", then I think that is the most effective test you can ever have done and the best indicator of your future health and longevity.

In Health
Jeff

[JeffN]

Another view of the validity of the cholesterol of 150

Total Cholesterol and Heart Attacks

https://www.crsociety.org/topic/11314-t ... t-attacks/

In Health
Jeff