Lowering Your Cholesterol With TLC

Y O U R G U I D E T O
Lowering Your
Cholesterol With TLC
U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES
National Institutes of Health
National Heart, Lung, and Blood Institute

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Y O U R G U I D E T O
Lowering Your
Cholesterol With TLC
U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES
National Institutes of Health
National Heart, Lung, and Blood Institute
NIH Publication No. 06–5235
December 2005

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Contents
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
Why Cholesterol Matters . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2
What Affects Cholesterol Levels? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4
Knowing Your Cholesterol Level . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5
Setting Your Goal . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
Treating High LDL Cholesterol . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13
The TLC Diet: A Heart Healthy Eating Plan. . . . . . . . . . . . . . . . . . . . . . . . 19
Foods To Choose for TLC . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30
Becoming Physically Active . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37
Maintaining a Healthy Weight. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43
Sample Menus for TLC . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 54
The Metabolic Syndrome—A Special Concern. . . . . . . . . . . . . . . . . . . . 70
Learning to Live the TLC Way. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 73
Keeping Track of Your Changes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 73
Be Smart When You Start . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 76
Reward Yourself . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 76
Making TLC a Family Affair . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 77
A Final Note . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 78
To Learn More . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 80
Contents

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1
Introduction
High blood cholesterol can affect anyone. It’s a serious condition
that increases the risk for heart disease, the number one killer of
Americans—women and men. The higher your blood cholesterol
level, the greater your risk.
Fortunately, if you have high blood cholesterol, there are steps you
can take to lower it and protect your health. This booklet will show
you how to take action by following the “TLC Program” for reduc-
ing high blood cholesterol. TLC stands for Therapeutic Lifestyle
Changes, a three-part program that uses diet, physical activity, and
weight management. Sometimes, drug treatment also is needed to
lower blood cholesterol enough. But even then, the TLC Program
should be followed.
The booklet has four main sections: It explains why cholesterol
matters and helps you find your heart disease risk; describes the
TLC Program; talks about a condition called the
metabolic syndrome that can also be treated
with TLC; and offers advice on how to
make heart healthy lifestyle changes.
Within the sections you’ll find tips on
such topics as how to: communicate
better with your doctor and other
health care professionals, read food
labels, make and stick with lifestyle
changes, plan heart healthy menus for the
whole family, and make heart healthy
choices when you eat out.
Anyone can develop high blood
cholesterol—everyone can take steps
Intr
to lower it.
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2
Why Cholesterol Matters
Cholesterol is a waxy, fat-like substance found in the walls of cells
in all parts of the body, from the nervous system to the liver to the
heart. The body uses cholesterol to make hormones, bile acids,
vitamin D, and other substances.
The body makes all the cholesterol it needs. Cholesterol circulates
in the bloodstream but cannot travel by itself. As with oil and
water, cholesterol (which is fatty) and blood (which is watery) do
not mix. So cholesterol travels in packages called lipoproteins,
which have fat (lipid) inside and protein outside.
Two main kinds of lipoproteins carry cholesterol in the blood:
? Low density lipoprotein, or LDL, which also is called the “bad”
cholesterol because it carries cholesterol to tissues, including the
arteries. Most of the cholesterol in the blood is the LDL form.
The higher the level of LDL cholesterol in the blood, the
greater your risk for heart disease.
? High density lipoprotein, or HDL, which also is called the
“good” cholesterol because it takes cholesterol from tissues to
the liver, which removes it from the body. A low level of HDL
cholesterol increases your risk for heart disease.
ith Therapeutic Lifestyle Changes
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If there is too much cholesterol in the blood, some of the excess can
become trapped in artery walls. Over time, this builds up and is
called plaque. The plaque can narrow vessels and make them less
flexible, a condition called atherosclerosis or “hardening of the
our Cholester
arteries.”
This process can happen to blood vessels anywhere in the body,
including those of the heart, which are called the coronary arteries.
If the coronary arteries become partly blocked by plaque, then the
blood may not be able to bring enough oxygen and nutrients to the
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heart muscle. This can cause chest pain, or angina. Some choles-
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terol-rich plaques are unstable—they have a thin covering and can
burst, releasing cholesterol and fat into the bloodstream. The
release can cause a blood clot to form over the plaque, blocking
blood flow through the artery—and causing a heart attack.
When atherosclerosis affects the coronary arteries, the condition is
called coronary heart disease or coronary artery disease. It is the
main type of heart disease and this booklet will refer to it simply as
heart disease.
Because high blood cholesterol affects the coronary arteries, it is
a major risk factor for heart disease. Risk factors are causes and
conditions that increase your chance of developing a disease.
Other major heart disease risk factors are given in Box 1.
B O X 1
Heart Disease Risk Factors
Risk factors are conditions or behaviors that increase your chance
of developing a disease. For heart disease, there are two types of
risk factors—those you can’t change and those you can. Fortunately,
most of the heart disease risk factors can be changed.
Risk factors you can’t change
? Age—45 or older for men; 55 or older for women
? Family history of early heart disease—father or brother
diagnosed before age 55, or mother or sister diagnosed
before age 65
Risk factors you can change
? Smoking
? High blood pressure
? High blood cholesterol
Why Cholester
? Overweight/obesity
? Physical inactivity
? Diabetes
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What Affects Cholesterol Levels?
Various factors can cause unhealthy cholesterol levels. Some of the
factors cannot be changed but most can be modified. The factors are:
Those you cannot change—
? Heredity. The amount of LDL cholesterol your body makes
and how fast it is removed from your body is determined partly
by genes. High blood cholesterol can run in families. However,
very few people are stuck with a high cholesterol just by heredity
—and everyone can take action to lower their cholesterol.
Furthermore, even if high cholesterol does not run in your family,
you can still develop it. High cholesterol is a common condition
among Americans, even young persons, and even those with no
family history of it.
? Age and sex. Blood cholesterol begins to rise around age 20
and continues to go up until about age 60 or 65. Before age 50,
men’s total cholesterol levels tend to be higher than those of
women of the same age—after age 50, the opposite happens.
That’s because with menopause, women’s LDL levels often rise.
Those under your control—
? Diet. Three nutrients in your diet make LDL levels rise:
• Saturated fat, a type of fat found mostly in foods that come
from animals;
• Trans fat, found mostly in foods made with hydrogenated oils
and fats (see pages 20–21) such as stick margarine, crackers,
and french fries; and
• Cholesterol, which comes only from animal products.
These nutrients will be discussed more later (see pages 19–23).
ith Therapeutic Lifestyle Changes
But it’s important to know that saturated fat raises your LDL
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cholesterol level more than anything else in your diet. Diets
with too much saturated fat, trans fat, and cholesterol are the
main cause for high levels of blood cholesterol—a leading
contributor to the high rate of heart attacks among Americans.
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? Overweight. Excess weight tends to increase your LDL level.
Also, it typically raises triglycerides, a fatty substance in the
blood and in food (see Box 2), and lowers HDL. Losing the
extra pounds may help lower your LDL and triglycerides, while
raising your HDL.
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B O X 2
What Are Triglycerides?
Triglycerides, which are produced in the liver, are another type of
fat found in the blood and in food. Causes of raised triglycerides
are overweight/obesity, physical inactivity, cigarette smoking,
excess alcohol intake, and a diet very high in carbohydrates
(60 percent of calories or higher). Recent research indicates that
triglyceride levels that are borderline high (150–199 mg/dL) or
high (200–499 mg/dL) may increase your risk for heart disease.
(Levels of 500 mg/dL or more need to be lowered with medication
to prevent the pancreas from becoming inflamed.) A triglyceride
level of 150 mg/dL or higher also is one of the risk factors of the
metabolic syndrome (see pages 70–72).
To reduce blood triglyceride levels: control your weight, be
physically active, don’t smoke, limit alcohol intake, and limit simple
sugars (see Box 20 on page 36) and sugar-sweetened beverages.
Sometimes, medication also is needed.
What Are Triglycerides?
? Physical inactivity. Being physically inactive contributes to
overweight and can raise LDL and lower HDL. Regular physical
activity can raise HDL and lower triglycerides, and can help
you lose weight and, in that way, help lower your LDL.
Knowing Your Cholesterol Level
You can have high cholesterol and not realize it. Most of the 65
million Americans with high cholesterol have no symptoms. So it’s
important to have your blood cholesterol levels checked. All adults
age 20 and older should have their cholesterol levels checked at least
Why Cholester
once every 5 years. If you have an elevated cholesterol, you’ll need
to have it tested more often. Talk with your doctor to find out how
often is best for you.
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The recommended cholesterol test is called a “lipoprotein profile.”
It measures the levels of total cholesterol (which includes the
cholesterol in all lipoproteins), LDL, HDL, and triglycerides. The
lipoprotein profile is done after a 9- to 12-hour fast. A small sample
of blood is taken from your finger or arm. If you don’t fast, you can
still have your total cholesterol and HDL levels measured.
The levels are measured as milligrams of cholesterol per deciliter of
blood, or mg/dL. Box 3 gives the classifications for total, LDL, and
HDL cholesterol.
Setting Your Goal
The main goal in treating high cholesterol is to lower your LDL
level. Studies have proven that lowering LDL can prevent heart
attacks and reduce deaths from heart disease in both men and
B O X 3
Cholesterol Classifications
Total Cholesterol
Less than 200 mg/dL
Desirable
200–239 mg/dL
Borderline high
240 mg/dL and above
High
LDL Cholesterol
Less than 100 mg/dL
Optimal (ideal)
100–129 mg/dL
Near optimal/above optimal
ith Therapeutic Lifestyle Changes
130–159 mg/dL
Borderline high
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160–189 mg/dL
High
190 mg/dL and above
Very high
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HDL Cholesterol
Less than 40 mg/dL
Major heart disease risk factor
60 mg/dL and above
Gives some protection against
heart disease
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7
women. It can slow, stop, or even reverse the buildup of plaque.
It also can lower the cholesterol content in unstable plaques, making
them more stable and less likely to burst and cause a heart attack.
Lowering LDL is especially important for those who already have
heart disease or have had a heart attack—it will reduce the risk of
another heart attack and can actually prolong life.
The level to which your LDL must be lowered depends on the risk
for developing heart disease or having a heart attack that you are
found to have at the start of treatment. The higher your risk, the
lower your goal LDL level.
The TLC Program uses four categories of heart disease risk to set
LDL goals and treatment steps. If you have heart disease or
diabetes, then you are in category I, which has the highest risk.
If you don’t have either of those conditions, then find your risk
category by doing the assessment in Box 4, which will send you to
Box 5 if needed.
The higher your risk category, the more important it is to lower
your LDL and control any other heart disease risk factors (including
smoking and high blood pressure) you have. Further, the higher
your risk category, the more you’ll benefit from taking action. But
whatever your risk category, you will use the TLC approach as a
basic part of your treatment.
Why Cholester
ol Matters

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Document Outline

• Contents
• Introduction
• Why Cholesterol Matters
  • What Affects Cholesterol Levels?
  • Knowing Your Cholesterol Level
  • Setting Your Goal
• Treating High LDL Cholesterol
  • The TLC Diet: A Heart Healthy Eating Plan
  • Foods To Choose for TLC
  • Becoming Physically Active
  • Maintaining a Healthy Weight.
  • Sample Menus for TLC
• The Metabolic Syndrome?A Special Concern
• Learning To Live the TLC Way
• Keeping Track of Your Changes
• Be SMART When You Start
• Reward Yourself
• Making TLC a Family Affair
• A Final Note
• To Learn More

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