The Good, the Bad and the Cholesterol Quiz

Answer: High-density lipoprotein and low-density lipoprotein

Blood triglyceride and cholesterol is, for the most part, packed with proteins in particles such as low-density lipoprotein (LDL) and high-density lipoprotein (HDL). Laboratories generally measure levels of triglyceride, cholesterol and high-density lipoprotein and then calculate the value of low-density lipoprotein from the other three utilizing the formula LDL = Cholesterol - HDL - Triglyceride/5.

This is possible because, in the fasting state, the bulk of triglyceride is carried in VLDL (very low density lipoprotein), the bulk of cholesterol is carried in LDL, HDL and VLDL particles.

When we eat, temporary triglyceride rich lipoproteins called "chylomicrons" are produced invalidating the above equation. It is possible but prohibitively expensive to measure LDL directly.

Answer: HDL

Numerous clinical trials have established a strong relation between LDL and HDL levels and coronary artery disease with increasing LDL predicting increased risk and increasing HDL predicting reduced risk. The dependence of atherosclerotic disease to triglyceride levels is both less strong and codependent on LDL and HDL levels.

Answer: All of these

A number of factors determine one's risk of arteriosclerotic vascular disease - cholesterol being a major but not dominant contributor. Multiple easily assessed risk factors as well as the level of cholesterol are likely to effect one's motivation to make lifestyle modifications and to accept therapy with medication.

Answer: She would have to smoke, have blood pressure 20 points higher and be 20 years older.

That all three additional risk factors would be needed to raise a women's risk to the level of the hypothetical man above can be confirmed utilizing the risk calculator that will be discussed below. A woman faces at least three challenges in deciding the optimum course of action with respect to cholesterol induced cardiovascular risk. First, she needs to avoid inappropriately risky or costly interventions if at very low risk. Second, a woman's decisions need to be guided by gender specific studies of risk reduction. Finally, she must avoid allowing a woman's relative protection from cardiovascular disease to result in too little intervention when she is at higher risk.

Answer: Total cholesterol and HDL

Both the National Cholesterol Education Program's calculator for men and women as well as the Reynolds Risk Calculator used only for women require only total cholesterol and HDL values. For both, non-fasting readings are acceptable. Both calculators are invalid for people with diabetics and for those with already known heart disease. The NCEP calculator was used for the creation of the prior quiz question.

NCEP risk calculator: http://hp2010.nhlbihin.net/atpiii/calculator.asp?usertype=prof

Reynolds Risk Calculator: http://www.reynoldsriskscore.org/faq.aspx

Answer: Both of these

Using the Reynolds Risk Calculator, the estimate obtained from the NCEP calculator can be refined for women, although it does require the addition of a measurement for high Sensitivity C-reactive protein and obtaining history of heart disease for one's parents.

There is another significant difference between the Reynolds and the NCEP calculation. The NCEP calculator only provides the risk of coronary artery disease manifesting as death or heart attack. The Reynolds Risk Factor utilized data on stroke, angioplasty (balloon surgery to open an artery), coronary artery bypass surgery as well as death or heart attack.

It is hoped that a similar instrument will be made available for men.

Answer: All of these

Restriction of dietary animal fat is effective in reducing LDL levels. Dietary recommendations from NCEP include limiting saturated fat to less than 7% of total calories. Polyunsaturated fat may make up to 10% of total calories, mono-saturated fat up to 20% of total calories, total fat 25%-35% of total calories but cholesterol is to be kept below 200 mg/d.

The percentage of fat is higher in cheeses, ice cream, mayonnaise and red meats than in whole milk or skinned chicken breast. Both elimination of foods containing saturated fat and substitution with foods lower in saturated fat can result in a lowering saturated fat and therefore LDL cholesterol.

Answer: Increased intake of trans-fatty acids in margarine

Trans-fatty acids are found in vegetable oils and lower beneficial HDL cholesterol levels. Products that certify an absence of trans-fatty acids are increasingly available, including margarines - a major potential source of dietary trans-fatty acids. Until labeling of trans-fatty acid content is required, careful evaluation of foods containing vegetable oil will be needed to lower one's intake of trans-fatty acids.

They are commonly found in packaged dessert and snack foods, margarines and shortenings.

Answer: Reduced cost

Although Niacin is a vitamin, when taken in the much higher amounts necessary to affect cholesterol levels, it acts as a drug altering the normal liver formation and metabolism of lipid packets. Doses that effectively reduce cardiovascular risk can be associated with both toxicity and side effects.

Not all people have a significant chance of benefiting from Niacin use and consultation with a physician can result in reduction of the risk of both side effects and toxic effects. The risk of liver damage from Niacin is dependent both on the dosage and type of Niacin preparation used.

In the United States, requirements for documentation of both efficacy and safety are far more stringent for prescription than over-the-counter medication. The safety of prescription "ER" (extended release) Niacin is better demonstrated than that of dietary-supplement "SR" niacin formulations. Finally, physicians can assist in the necessary dosage titration, can advise regarding side effects as well as monitoring for toxicity that can include liver test abnormality, blood sugar elevation and provocation of gout attacks. (Safety Considerations with Niacin Therapy The American Journal of Cardiology - Volume 99, Issue 6A, March 2007)

Answer: Folic acid induced lowering of homocysteine levels

The results of studies involving homocysteine and cardiovascular risk reduction are a cautionary tale. Studies demonstrated a significant and clear-cut relationship between homocysteine levels and the risk of coronary and cerebrovascular events. Folic acid has been shown to effectively reduce homocysteine levels. Yet, numerous studies have demonstrated that folic acid induced reduction of homocysteine levels in patients in whom the levels were elevated resulted in no reduction in cardiovascular or cerebrovascular risk. Similarly, some medications that effectively lower blood pressure have been found NOT to protect against cardiovascular events. Physicians and patients would probably do well to consider the strength of the evidence for risk reduction as well as the untreated risk of a vascular event in making treatment decisions. For instance, should a low risk patient use a seemingly safe but unproven treatment? How about a high risk patient?