Why does my doc care about my cholesterol?

         For the past 30 years doctors have been able to measure cholesterol levels and use that information to lower the risk of coronary artery disease. When a cholesterol plaque ruptures within your coronary artery a small clot forms over the plaque and a heart attack occurs. It is for this reason that I work so hard with patients to lower their cholesterol levels. Typically when we check cholesterol we check 5 components: Total Cholesterol, HDL (high density lipoprotein), LDL (low density lipoprotein), Triglycerides, and I like a Cholesterol/HDL ratio. There are a number of other particles that can be checked including Lp(a) and Apoprotein (b).

The LDL is what has traditionally been the biggest concern to doctors as it is the primary contributor to cholesterol plaque formation. Ideally, LDL values will be less than 130mg/dl in healthy people and we try to get them below 70mg/dl for patients with diabetes or known coronary artery disease.  We think of HDL as the scavenger or repair brigade, these particles repair damage to artery walls so that cholesterol plaques do not occur, the higher this number is the better, ideally over 50mg/dl in adults. The triglycerides transport fat in our bodies and are not an independent risk for coronary artery disease but they are indicators of Metabolic Syndrome (high triglycerides , low HDL, elevated blood sugar, and hypertension) which make diabetes and coronary artery disease more likely. The ratio of Cholesterol/HDL ratio provides us what proportion of total choles terol is the good cholesterol and we like to see this ratio less than 5.0 (i.e. Total Cholesterol 180mg/dl/HDL 50mg/dl=Ratio 3.6).  Other risk factor for coronary artery disease that we can modify are smoking and hypertension. 

A simple tool that you can use to calculate your risk for coronary artery disease is the Framingham Risk Calculator. The Framingham Risk Calculator was developed using data that was collected during the The Framingham Heart Study which analyzed approximately 5000 men and women from Framingham Massachusetts for over 50 years to determine risk factors for cardiovascular disease. Using the Framingham Risk Calculator we can determine whether or not a patient between 34-74 years old needs medical management of their risk factors for cardiovascular disease. Interestingly, we only can hypothesize about people older and younger than 34-74 years old, but  we can infer that having a good cholesterol profile, a healthy diet, an active life style, and blood pressure awareness prior to age 34 will lower your risk of having cardiovascular disease. I think we will look at other risk factors to help us predict who will develop cardiovascular disease including genetics, infections and associated systemic inflammation, and other small cholesterol particles. For now, I think the most important thing you can do beyond having your cholesterol measured is to stay active and eat a low fat, low cholesterol diet. 

Dollars for Doughnuts

An interesting article came out this week in the Annals of Internal Medicine which reported that people lost considerable weight when give financial incentives compared with people who were encouraged to lose weight because of long term health benefits. In addition, the greater/stronger the reward the more weight people lost. Participants were obese workers at a Children’s hospital in Philadelphia. Participants were divided into 3 groups which were followed over 6 months. The first was an individual payment of $100 per month if you met your weight loss goal, the second was a group payment of $500 where 5 people were eligible to divide the pot among all participants who met the goal, and the third group were asked to lose weight because of long term health benefits and were weighed and encouraged each month but had no financial incentive. Not surprisingly, the people who had the most to win (the $500 pot) lost the most (10lbs ) followed by the $100 dollar group (5lbs), then the no financial incentive group (1lbs). In 12 weeks following the study most of the participants gained the weight back, but some of the weight loss persisted across the groups. 
One interesting insight was that when people are challenged to do something and offered a meaningful reward they can learn new ways of doing things, or reprogram their brain. In the study people who had been obese for some time were able to learn restraint from poor food choices and engage in exercise because they were going to be rewarded. Once the incentives were taken away, the new learned behaviors persisted for some time but eventually faded. 
The study was done to look at strategies that employers could use with the upcoming implementation of of the Affordable Care Act to lower their potential health care costs by encouraging overall better health of their employees. Practically, this study can be applied in our daily lives. Why can’t we incentivize ourselves with a monthly massage or other luxury if we make our goal weight, or form groups to participate in Biggest Loser type competitions with meaningful prizes . The evidence seems clear that if an individual is trying to lose weight they need to be incentivized beyond the health benefits of healthy eating and the benefits must be extended indefinitely. Practically, long term financial incentives do not make sense for all employers but for individuals, families, and groups of friends it is easy to see how by shifting the lens from “I need to lose weight to be healthy,” to “If I lose weight I get something pleasurable,” will lead to better long term weight control and people will reprogram their eating habits. The term for this phenomena is “cognitive restraint” in other words people do better when they are asked to choose between doughnuts and dollars than doughnuts and an abstract concept such as long term health. If cognitive restraint is practiced long enough hopefully the healthy eating habits will replace the old poor eating habits and monetary reward will be replaced by good self esteem and positive reinforcement from our friends and family over our new healthy appearance.