cholesterol

Medical Q&A [Moderated]
1

Hello Doctors,

I recently had some routine blood work done and it turns out my cholesterol was high. The numbers are here:

Cholesterol 281 (H) 07/18/2022
HDL 42 (L)
LDL CALCULATED, NONFASTING 179 (H)
TRIGLYCERIDE, NONFASTING 301

When my Kaiser MD responded to me she said my blood work was all within normal range. I don’t know if she just overlooked the numbers or if they are not concerning to her but when I looked at the numbers myself (and then read your 3 articles on cholesterol), I pushed back and said the cholesterol seemed high. She responded with this

“Yes, your HDL was lower than ideal and your LDL bad cholesterol was higher than ideal. Triglycerides are a bit high. I recommend cutting down on processed carbohydrates and snacking”.

I found that guidance to be very unspecific and not helpful. Additionally I have a family history of people dying in their early 50s from heart attacks (I’m 45). I also had a pulmonary embolism last summer (which wasn’t taken seriously until I ended up in the ER for 9 hours- that is a different long story about learning to trust my experience and advocate for my own health care). All of this said I have the following questions:

  1. Are these numbers concerning to you?
  2. Do you think these are numbers that could be changed via diet and exercise? According to 23 and me I do not have the hypercholesterolemia genes APOB and LDLR.
  3. These numbers went up quite a bit in just 1 year. Could this be from my newish cold brew coffee habit where I drink 13 oz a day? Could it be from officially being in menopause? Could it be a different reason?
  4. Despite her advice above, I made an appointment with my MD to request more. I have found that I need to advocate strongly for myself and push for the health care I need. I want to be sure that I have the information I need for the appointment and to ask the right questions in my appointment. Are there any questions you recommend I bring up in my upcoming appointment?

Thank you for your help with this!

2

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When my Kaiser MD responded to me she said my blood work was all within normal range. I don’t know if she just overlooked the numbers or if they are not concerning to her but when I looked at the numbers myself (and then read your 3 articles on cholesterol), I pushed back and said the cholesterol seemed high. She responded with this

“Yes, your HDL was lower than ideal and your LDL bad cholesterol was higher than ideal. Triglycerides are a bit high. I recommend cutting down on processed carbohydrates and snacking”.

I found that guidance to be very unspecific and not helpful. Additionally I have a family history of people dying in their early 50s from heart attacks (I’m 45). I also had a pulmonary embolism last summer (which wasn’t taken seriously until I ended up in the ER for 9 hours- that is a different long story about learning to trust my experience and advocate for my own health care). All of this said I have the following questions:

I agree that this is vague and generally unhelpful advice. Your family history is indeed concerning as well.

  1. Are these numbers concerning to you?

Yes, they are.

  1. Do you think these are numbers that could be changed via diet and exercise? According to 23 and me I do not have the hypercholesterolemia genes APOB and LDLR.

They can be influenced via the lifestyle steps discussed in the article series, yes. Whether that would be enough to achieve goal levels is a different question that’s harder to answer without more information.

  1. These numbers went up quite a bit in just 1 year. Could this be from my newish cold brew coffee habit where I drink 13 oz a day? Could it be from officially being in menopause? Could it be a different reason?

Unfiltered coffee in particular does have an effect on raising LDL-c, however I would not expect it to impact triglycerides nearly as much in this way. A variety of changes in the menopausal state may contribute, but would ultimately not change our recommendations for how this situation should be managed.

  1. Despite her advice above, I made an appointment with my MD to request more. I have found that I need to advocate strongly for myself and push for the health care I need. I want to be sure that I have the information I need for the appointment and to ask the right questions in my appointment. Are there any questions you recommend I bring up in my upcoming appointment?

Your doctor may not be taking things as seriously because you are only 45 years old, and because current guidelines (which I think fall short) are still fixated on 10-year risk estimates, but not beyond that. Given how young you are, your lifetime risk of cardiovascular disease remains high if the blood lipids are left in this range long-term, even if your 10-year risk is relatively low. For example, if I input your information into this risk calculator (making some assumptions about your other information that was not provided here, but assuming “best case” scenarios), I get a 10-year risk of only 1.9% (very low), but a lifetime risk of 39%, which is significant. This perspective of managing lifetime risk, not just 10-year risk, is the direction things are headed in my opinion (and is how I practice).

If the physician remains unconcerned after all of this, I would seek care with someone else. In the meantime, following the recommended steps in Part 2 of the article series would still be the best place to start.

3

Hi Dr. Baraki,

Thank you so much for this response! I will bring up the idea of lifetime risk in my appointment. It is nice to know that I am right to be concerned. That gives me confidence about getting the treatment I need and finding a different physician if necessary. Since reading your cholesterol articles I have made it a goal to increase my fiber intake to 30g at day. Since I’ve done this I’ve been hitting closer to 40g a day. I have to say, the fear of having a heart attack is quite motivating. Thank you for all of the work you do!

4

One more question- I just went to use the risk calculator that you linked to. I looked up my blood pressure at my last visit- it was 122/45. The calculator made me input a Diastolic Blood Pressure number of at least 60 which has made me wonder if this blood pressure is concerning?

5

That is a bit on the low side for a diastolic pressure, but this number is tough to interpret in isolation. If you felt fine I wouldn’t be too concerned about that for now and just keep monitoring as usual.