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MARGARET WARNER: Tens of millions more Americans could be judged at risk for heart disease under today’s new standards for cholesterol testing and management. The new guidelines come from the National Cholesterol Education Program, under the auspices of the National Institutes of Health. Here to tell us about them is the program’s coordinator, Dr. James Cleeman. Welcome, Dr. Cleeman.
DR. JAMES CLEEMAN: It’s a pleasure to be here.
MARGARET WARNER: Okay. First of all, remind us: What is cholesterol; why is it so important to overall health?
DR. JAMES CLEEMAN: Cholesterol is a waxy substance that is necessary for many bodily functions, including, for example, making of hormones, but if there is too much cholesterol in the blood, it is deposited in the walls of the arteries, causes plaque, eventually blockage of the artery can occur, and if a clot forms on top of that plaque, it can actually cause a heart attack. So high cholesterol is known to be an important case of heart attack.
MARGARET WARNER: Now, you last issued guidelines, or this program did, just eight years ago. Why revise them now?
DR. JAMES CLEEMAN: What we have now is new evidence about how serious a problem elevated cholesterol is and new evidence about how effective it is to lower cholesterol. There are millions of Americans who are at higher risk for heart disease and heart attack than we have previously recognized. And lowering their LDL, bad cholesterol, is enormously beneficial. We see from the clinical trials and from the studies that if you lower LDL cholesterol, you reduce the risk for a heart attack, for death from heart disease, and for the overall death rate actually comes down also. So this is an enormously important maneuver.
MARGARET WARNER: All right. Let’s talk about the so-called LDL and explain what it is and why it’s bad and then how much tougher your new standards are.
DR. JAMES CLEEMAN: LDL cholesterol is called bad cholesterol because the LDL is low-density lipoprotein. That’s what LDL stands for. A lipoprotein is a mixture of lipid fat and protein. Fat can’t travel in the blood very well because the blood is watery, so it’s got to be mixed with a protein and travel in that form. And the cholesterol that is brought by LDL is on its way to the bodily tissues, including the arteries where it is deposited and causes plaque, blockage and heart attack; whereas good cholesterol, HDL cholesterol, high density lipoprotein, is cholesterol on its way back from the bodily tissues on its way to the liver for processing and therefore is being removed from the body.
MARGARET WARNER: So you all have– we have got a graphic to show this– lowered or revised the standards for risk with this bad cholesterol. Why don’t you just explain. Here is the old standard.
DR. JAMES CLEEMAN: Okay. The old standard, as you can see, had a level of less than 130 as desirable. That was the finest cut we made as… in terms of the low levels. The other levels have not been changed, 130-159 was then borderline. 160 and above was high. But now….
MARGARET WARNER: The new one.
DR. JAMES CLEEMAN: In terms of the new one you see below 130 there is now a cut. Less than 100 is identified as optimal and 100-129 is both near optimal, if you are coming down from a very high level, you are getting close to optimal, it’s near optimal. But if you started at that level and have a cholesterol problem, it is actually above optimal.
MARGARET WARNER: So how many millions more Americans are now at risk that didn’t know yesterday they were at risk?
DR. JAMES CLEEMAN: Well, what’s important about the new guidelines and their risk estimation is not just that they change the cut points for LDL, but that they identify many people who have just as high risk for a heart attack as people who have heart disease itself. And these include people with diabetes and people with two or more risk factors for heart who find when the risk is calculated that their risk for a heart attack within a decade exceeds 20 percent. That doesn’t… That may not sound like a lot, greater than 20 percent, but it is the very risk level of a person who already has heart disease and they have five to seven times as high a risk of heart attack as somebody walking around without heart disease.
MARGARET WARNER: Really today, your… you’re saying or you’re releasing data that shows that you could have a higher risk than you thought — either because your cholesterol — your bad cholesterol is higher than now it should be or that you have diabetes or that you have some of these other risk factors.
DR. JAMES CLEEMAN: In combination with your LDL, these other risk factors can multiply the risk and you may find out that somebody who had a fairly innocuous looking total cholesterol, today we talked about an example of somebody who had a total cholesterol of 190 which under the previous guidelines was a desirable total cholesterol and still is today and nevertheless because of other risk factors may actually have as high a risk for heart attack as a person with heart disease. Those people need to have their LDL’s lowered to less…
MARGARET WARNER: The bad cholesterol.
DR. JAMES CLEEMAN: The LDL bad cholesterol to less than 100, and that will, in many people, require a combination, excuse me, require a combination of therapeutic lifestyle changes, diet, physical activity, weight control and medication.
MARGARET WARNER: All right. Let’s talk first about the lifestyle changes, because we’ve always heard, all right, less fat, more exercise. That’s what you’ve got to do. What’s new here?
DR. JAMES CLEEMAN: What’s new here is that the combination of therapeutic lifestyle changes beg recommended is far more effective than what had been seen previously. We are recommending that the patient not go to a stepped approach to lowering the saturated fat and cholesterol in the diet but go straight to the lower level, less than 7 percent of calories from saturated fat, less than 200 milligrams a day of cholesterol. In addition, if that doesn’t produce enough lowering of the bad cholesterol, there is available the addition to the diet of what we call stanols and sterols; these are substances that are now available in foods like margarine and salad dressings that can help lower the bad cholesterol by blocking the absorption of cholesterol in the first place and also the addition of fiber to the diet. We now have better evidence than ever before that those maneuvers actually help lower bad cholesterol. And then you have added emphasis on physical activity and on weight control. You put them altogether, what you get is a greater than 20 percent reduction in the bad cholesterol. That’s much more effective than had been the case previously.
MARGARET WARNER: Just explaining for people who don’t know, saturated fat, the bad fat is all the fat that comes from animal products, the dairy products….
DR. JAMES CLEEMAN: Saturated fat is fat that is hard at room or refrigerated temperature. It largely comes from animal sources. There is actually a couple of plant sources that are saturated fat also: Palm oil, palm colonel oil and coconut oil, those are also saturated.
MARGARET WARNER: All right. Now on to the cholesterol lowering drugs because that’s a big part of your news today. You think a lot more people may need to be on these drugs.
DR. JAMES CLEEMAN: Because so many more people are at risk for heart attack, those with diabetes, those with multiple risk factors, and a high decade’s risk, a high ten-year risk for having a heart attack, those people need to lower their cholesterol, their LDL bad cholesterol down to less than 100; and in order to get there for very many of them, the therapeutic lifestyle changes will do a lot but may not get them the whole way. And so you have to add medication. We think that whereas previously 13 million people would have qualified to have medication added to the mix, now 36 million people will need to have medication added to the mix.
MARGARET WARNER: That’s nearly one in five Americans.
DR. JAMES CLEEMAN: That’s…
MARGARET WARNER: Adult Americans.
DR. JAMES CLEEMAN: That’s not surprising, given the fact that we have an epidemic of coronary disease in this country and that coronary disease, heart disease, is the number one killer of women and men despite the progress that has been made against both heart disease and cholesterol in the last decades. So we know there are a lot of risk factors out there. We know that people with diabetes have a very high risk of a heart attack. And we have to do something about it in an aggressive way if we really want to make a dent in this problem.
MARGARET WARNER: So finally to sum up, how many people, how many Americans are really aware of this problem, are aware of their own levels and are doctors and patients doing enough now to, one, increase their awareness and, two, to do something about it?
DR. JAMES CLEEMAN: This is a good news, bad news story. The good news is things have gotten much better since before the program was launched.
MARGARET WARNER: Your program.
DR. JAMES CLEEMAN: — Cholesterol Education Program. We have data. We have data that tell us that in 1983, which was two years before the launch of the program, only 35 percent of the American public had ever had their cholesterol checked. In 1995, that level had come up to 75 percent of the American public. The difference of 40 percent, from 35 percent to 75 percent is an absolute difference of 80 million Americans who had done something to find out. Now while that’s good new, not enough is really being done to treat those cholesterol levels. We know, for example, that about 80 to 85 percent of people with heart disease itself would benefit from bad cholesterol lowering, LDL cholesterol lowering. Only half of those people are getting treated for lowering their bad cholesterol.
MARGARET WARNER: Why?
DR. JAMES CLEEMAN: And only 20 percent are reaching their goal level. I think it’s because there hasn’t been enough clarity about what needs to be done and because there’s been a little concern about how high you can go with the doses of the drugs involved. But now with the new data and the new evidence telling us both how beneficial it is and how safe it is, I think we will see– and well with our efforts to try to encourage implementation of the guidelines– I think we will see them really take effect.
MARGARET WARNER: All right. Well, Dr. Cleeman, thanks for bringing some clarity to this for us. Thanks.
DR. JAMES CLEEMAN: Thank you.