1. Let’s Talk About Cholesterol Emily Lundstrom, R.Ph., Pharm.D. Melissa Kalb, RD, LD August 8, 2007

2. Outline Discuss the different types of cholesterol Identify healthy cholesterol levels Provide an overview of medications used to treat abnormal cholesterol levels Discuss options for a low cholesterol diet

3. What is cholesterol? Fat-like, waxy substance Cholesterol comes from two sources The food you eat and your liver

4. Why do we need cholesterol? Some is needed for bodily functions To make cells and some hormones Too much cholesterol Clogs arteries Causes heart attack or stroke

5. Types of Cholesterol LDL Cholesterol-”Lousy” Cholesterol HDL Cholesterol-”Happy” Cholesterol Triglycerides Which is the most important? LDL HDL & Triglycerides are a close 2 nd and 3 rd

6. LDL—The “Lousy” Cholesterol Contributes to build up of fat deposits in arteries Decreases blood flow to the heart Want this to be low Lowered by diet, exercise, and most medications

7. HDL—The “Happy” Cholesterol Helps carry “bad” cholesterol away from arteries to liver The higher the better! How can you raise your HDL? Exercise Some medications help Eating properly may help

8. Triglycerides Most common type of fat in the body Comes mostly from diet Things that increase triglycerides

9. What Level of Cholesterol is good? Total cholesterol <200 Triglycerides <150 HDL—”Happy” Cholesterol >40 LDL—”Lousy” Cholesterol <100? * LDL goal depends on other health conditions or risk factors

10. Medications “Statins” Bile acid binders Nicotinic acid (“Niacin”) Fibric Acids Cholesterol absorption inhibitors Fish Oil

11. “Statins” Lipitor® (atorvastatin) Zocor® (simvastatin)* Pravachol® (pravastatin)* Crestor® (rosuvastatin) Lescol® (fluvastatin)* Mevacor® (lovastatin)* *Indicates generic available

12. “Statins” LDL Triglycerides HDL Well tolerated Could experience headache, constipation, stomach cramps or gas A small number of patients experience muscle pain or weakness Will require liver tests Most need to be taken before bed

13. Bile Acid Binders LDL Triglycerides HDL Mix powders with water, juice, or food Space from other medications Side effects: Constipation, nausea, gas Questran® (cholestyramine)* Colestid® (colestipol) Welchol® (colesevelam) *Indicates generic available

14. Nicotinic Acid (Niacin) HDL Triglycerides LDL Vitamin B3 May cause flushing and itching Take with food Niacor ® *, Niaspan ® *, Slo-Niacin ® * OTC *Indicates generic available

15. Fibric Acids Triglycerides HDL LDL Take with food Side effects: Nausea, diarrhea, constipation May cause muscle pain or weakness Lopid® (gemfibrozil)* Tricor® or Triglide® (fenofibrate) *Indicates generic available

16. Cholesterol Absorption Inhibitors Zetia® (ezetimibe) Stops cholesterol absorption from food Does not have to be taken with food Often combined with a “statin” LDL Side effects: headache, abdominal pain, diarrhea

17. Fish Oil Omacor® Rx only FDA Approved $$ Expensive $$ * Now called Lovaza® Omega-3 Supplement Over-the-counter Not FDA Approved Inexpensive Triglycerides

18. Two-In-One Combination medications available: Vytorin® (simvastatin + ezetimibe) Advicor® (lovastatin + Niaspan) Pravigard PAC® (pravastatin + aspirin)

19. References American Heart Association. Accessed at http://www.americanheart.org National Heart, Lung, and Blood Institute. Accessed at http://www.nhlbi.nih.gov/ Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults. Executive Summary of The Third Report of The National Cholesterol Education Program (NCEP) Expert Panel on Detection, Evaluation, And Treatment of High Blood Cholesterol In Adults (Adult Treatment Panel III. JAMA. 2001; 285:2486-97.

20. References Grundy SM, Cleeman JI, Merz CN et al. Implications of recent clinical trials for the National Cholesterol Education Program Adult Treatment Panel III guidelines. Circulation. 2004; 110: 227-39.

21. Low Cholesterol Diet Melissa Kalb, RD, LD

22. Therapeutic Lifestyle Changes (TLC) Limit saturated fats and trans fats Limit cholesterol Eat more omega-3 fats Monitor total fat intake 25-35 grams of fiber per day Include meat alternatives Weight loss Exercise

23. Saturated Fats Generally from animal or dairy sources Also from coconut and palm oils Items to limit = marbled meat, poultry skin, bacon, sausage, whole milk, cream, butter

24. Trans Fats Process that turns an unsaturated (healthier fat) into saturated fats Items to limit = stick margarine, shortening, some fried foods, and packaged foods made with hydrogenated oils

25. Cholesterol TLC goal = 200 milligrams per day American Heart Association = 300 milligrams per day Items to avoid – egg yolks, fatty meat, whole milk, cheese, shrimp, lobster, and crab.

26. Omega-3 Fats These fats may help to reduce your risk of heart disease Good sources = salmon, tuna, mackerel, walnuts, canola soybean and flaxseed oil.

27. Total fat intake 25% to 35% of total calories Including heart-healthy fats

28. Fiber Goal = 20 – 30 grams per day Soluble fiber – helps to lower LDL (“bad”) cholesterol Sources: oats, beans, peas, citrus fruits, strawberries, apple pulp Insoluble fiber – helps to decrease your cardiovascular risk Sources: whole wheat bread, wheat cereals, cabbage, carrots, cauliflower, apple skin

29. Meat Alternatives Meat and cheese can be high in saturated fats Items to try = soy burgers, and beans in casseroles

30. Weight Loss and Exercise Following lifestyle changes Speak with your health care team to determine an exercise plan

31. Healthy Lifestyle and Medication Do I need to follow a healthy lifestyle if I am taking my medication?

32. Questions??? Emily Lundstrom, Pharm.D. emily.lundstrom@osumc.edu Chris Green, Pharm.D. christopher.green@osumc.edu Melissa Kalb, RD, LD melissa.kalb@osumc.edu