Dear DOCTOR Owen:

My doctor recently prescribed cholesterol medication for me after I lost 25 pounds. But it has caused little change in my blood cholesterol level. I lost the weight after being on a very low fat diet. My friend normalized her level and avoided medication. Should I continue to try dieting to control my cholesterol?

Medicated

Dear “Medicated”:

You probably are genetically under-blessed. Some people simply make too much cholesterol; diet plays a very minor role. The liver controls cholesterol synthesis in the body. The rate of synthesis is controlled by genetics, but influenced by food. The amount of saturated fat influences cholesterol production. Simple sugars raise insulin levels in the blood, which activate the enzymes that promote cholesterol production. Fats activate HMG-CoReductase, one of the main enzymes affected by cholesterol medication.

All factors must be considered when looking at cholesterol levels. The cholesterol level is the number-one predictor of future heart attack or stroke. Add cigarettes—and the situation is a “slam-dunk”! But the cholesterol level is only a predictor, not a guarantee. A group of Northeastern Italians in the Alps have cholesterol levels in the 500s, but rarely get atherosclerosis.

Family history is also important. Smoking, a sedentary lifestyle, diabetes, high blood pressure, and so on contribute to additional risk. Remember: Approximately 70% of Americans over the age of 40 will die of cholesterol. On the other hand, a “good” cholesterol level does not guarantee safety.

I recommend an artery ultrasound, preferably of the carotid artery, to see if cholesterol is accumulating and how much is present. While a picture is not only worth 1,000 words, it can also be referred to when checking on the results of treatment. An article in The New England Journal of Medicine (January 1999) confirmed that the ultrasound is a worthwhile test, as it helps the doctor decide if a patient needs to take a drug forever. Further, it helps the doctor explain to the patient why he or she needs to take the drug over the long term. Patients’ compliance with medication—usually from fear of effects and side effects or exorbitant costliness—has become a great problem for treating physicians.

Ultrasounds of the carotid artery are offered at all hospitals, in most the offices of most cardiologists, and now can even at, places of worship, malls, and so on. Ask your doctor about this test or look for postings for screenings in public places.

To lower cholesterol, doctors usually recommend diets that are low in fat and simple sugars, as well as diets with reduced calories for people who are overweight. The commercially promoted diets, Sugar Busters!TM and the Atkins’ Diet Revolution, which promotes a high-protein, high-fat, but low-sugar strategy, have ruffled the feathers of the dietitian community. Some preliminary studies suggest that—in some cases—these diets actually may reduce cholesterol in spite of a high-fat level,. My guess is that the 30% of the population that becomes insulin-resistant, or “pre-diabetic,” will benefit the most from these diets. Such diets may be an option for you, with supervision by your doctor.

I personally take cholesterol medication and use fat-blocking drugs when I eat high fat. I recently heard a cardiologist suggest that we put cholesterol medication into the drinking water because we’re all dying of clogged arteries. Maybe the “cholesterol police” will get their way one of these days!