What I tell my patients is:
1. If they're fat or out of shape, then they need to exercise more, and eat less. If they're lean and in shape, they're probably eating and exercising enough already, and just need to eat the
right foods and use appropriate medication to reduce their cardiovascular risk.
2. If their heart rate at work stays - for 30 minutes at a time - at 80% of 200 minus their age (the 'aerobic' range), they may count that time as 'exercise' - otherwise all their 'active' job does is wear them out so they are too tired when they get home to actually get real exercise. Seriously -
not many guys get their heart rate to 120 or so for any amount of time at work...!
3. Since exercise is boring, get a recumbent magnetic bike (nearly silent, easy on the back and knees, and easy to adjust for shared users), and put it where there is a television or good stereo. Right in the livingroom if necessary.
4. They should not depend on the regular "LDL" cholesterol level - it is NOT a reliable measure of their 'cholesterol' risk (the number of particles, LDL-P, DOES correleate with risk, but many patients are not offered the test because it may not be covered by insurance, and the may even be penalized for ordering it, as it diverts profits away from the local laboratory insurance or the VA has contracted with). Getting an LDL-P such as the Lipoprofile from Liposcience is vital.
5. If their LDL-P to LDL-C ratio is over 16 or if their Trig/HDL ratio is over 3, they should be on a diabetic-type diet like the South Beach one, because they are likely on the verge of diabetes, and are at least insulin resistant. They should also get an insulin level, fasting and total testosterone levels, 25-OH vitamin D level, and 1 and 2 hour glucose tolerance test, in my opinion. Some doctors would add an A1C, HS-CRP, and Lp-PLA-2 test at that point, if the patient really wants to avoid heart attack or stroke (they will assume the patients who only want to do 'what insurance covers', aren't really that motivated to avoid heart attack or stroke).
6. Beef I think is ok, if the cholesterol is at goal, although I tell patients to avoid any meat with hormone residues (i.e. animals with 'pellet implants') - guys have enough problems with their "low-T" (testosterone dropping), and don't need synthetic estrogens on board to add to that problem, nor do women need extra and abnormal estrogens confusing their breast tissue.
Here's a typical dilemma we come across every day, in a case study:
http://www.lipidcenter.com wrote:
I was contacted by a practitioner working in a CV clinic who stated "we have a diabetic patient with bad vascular disease who is on insulin, Lipitor 40 mg and Zetia 10 mg among other meds. He has had coronary stents in 2007 and 2008, has a pacemaker and ICD. His lipid and lipoprotein NMR results are as follows:
- Total Cholesterol = 101
HDL = 35
Triglycerides = 92
LDL = 48
Non-HDL-C = 66
TC/HDL-C = 2.8
LDL-P= 980 (small LDL-P = 726)
The patient's cardiologist is suggesting that he decrease his Lipitor to 20 mg because his last
standard lipid panel done by the VA (not an NMR) showed:
- Total Cholesterol = 81
HDL = 34
Triglycerides = 43
LDL of 39
The provider disagreed with Cardiology and stated "with his NMR results and the fact that his small LDL-P = 726, we wanted him to continue his current regime." My advice was sought.
DAYSPRING DISCUSSION: This is easy and the answer is supported by lots of studies and expert opinion. The provider is correct and
the cardiologist is wrong. If anything makes the case for lipoprotein, in addition to lipid testing, this case does. No one would disagree this is a very high risk patient which deserves aggressive lifestyle and pharmacologic support.
.......
Finally Alan Sniderman in a review of over 17,000 patients taking statins and having lipid panels, apoB and LDL-P measurements has commented on this phenomenon in the Journal of Clinical Lipidology 2008;2:36–42 and he states "Many patients who achieve LDL-C and non–HDL-C target levels will not have achieved correspondingly low population-equivalent ApoB or LDL-P targets.
Reliance on LDL-C and non–HDL-C can create a treatment gap in which the opportunity to give maximal LDL-lowering therapy is lost.
Now having said all that, you should always check with YOUR physician(s) before making diet, exercise, or medication decisions. I'm just saying that too many physicians are NOT paying attention to the current evidence, because they are EMPLOYEES vs. independent professionals, and thus are more focused on doing what their employer rewards them for, which is going to be whatever keeps the most profits in-house.