When my endocrinologist suggested earlier this month that I go on a statin to lower my LDL (damn you, diabetes!), I didn’t love the idea. I agreed to think about it, but in truth, I began at once exploring alternatives. To begin with, I wanted to understand if my lipid numbers were in fact problematic.
Should I even worry about my cholesterol levels?
According to the American Diabetes Association (ADA), people with diabetes should meet the following targets:
- LDL (aka "bad") Cholesterol: < 100 mg/dl
- HDL (aka "good") Cholesterol: > 40 mg/dl (men) and > 50 mg/dl (women)
- Triglycerides: < 150 mg/dl
The role of cholesterol in our bodies seems poorly understood. For years I believed in the protective benefit of HDL - the idea that a high HDL would offset a high-ish LDL. But this 2012 New York Times article points out that view may be outdated.
(So a high HDL isn't necessarily helping me avert heart disease?) I was further encouraged by another briefly popular notion that what mattered more than the individual numbers was the ratio of HDL to total serum cholesterol. The American Heart Association (AHA) has stated that a ratio of <3.5:1 is ideal. And yet, the AHA has not incorporated the metric into their clinical practice guidelines. (So much for my own reassuring ratio of 3.55:1.)
Therefore, barring other measurements, I am resigned to the fact that the individual cholesterol numbers matter at this moment in time. Which leads to the question of treatment:
Should I lower my LDL with a statin?
Again, according to the ADA, yes. The ADA maintains that:
Statin therapy should be added to lifestyle therapy, regardless of baseline lipid levels, for diabetic patients without CVD (cardiovascular disease) who are over the age of 40 years and have one or more other CVD risk factors (family history of CVD, hypertension, smoking, dyslipidemia, or albuminuria.
There’s no question that statins lower cholesterol, but for whom, to what degree, and with what effect remain unclear. Statins' success in secondary prevention – helping people (particularly men) avert a second heart attack or stroke – is well documented. But their effectiveness for primary prevention (initial heart attack/stroke) is less clear. It turns out that cholesterol levels may be less predictive of cardiovascular disease (CVD) than previously thought. (This 2012 Journal of American Medicine piece suggests the controversy).
Even if the indication were more certain, the benefits would have to outweigh the potential side effects linked to statin use (see the FDA's current consumer advisory on statins), notable among them: muscle pain, cognitive interference, and – wait for it – elevated blood sugar.
On the NIH’s National Heart, Lung and Blood Institute website, I found a simple (now outdated) risk assessment calculator* where you can plug in different cholesterol numbers and see how they affect your 10-year risk of heart attack.
(I calculated mine based on my recent lab work: 1% risk. Not very statin-worthy.)
* 11/12/2013 update: new cholesterol treatment guidelines were published today. Per these new recommendations, anyone between the ages of 40 and 75 who has Type 1 or Type 2 diabetes should be on a statin (period). However, I used the brand new calculator (which now includes stroke risk) to gauge my 10-year risk of heart attack or stroke. .04%. So, thanks, I guess, for the new guidelines, but I'll still pass on the statin for now.
Despite my skepticism, I don’t want to give my newish endocrinologist the impression that I ignore her advice. There seems to be no harm in trying to lower my LDL naturally.
My plan to reduce my LDL without a statin
Reputable web sites assure me that diet and exercise may help lower my LDL by 20-30%. The added bonus for me is that I’ll get more fit in the process. Excellent! So:
- I upped my gym visits to 5-7 days/week.
- I found my long-lost pedometer and am logging at least 7500 steps/day.
- Oatmeal or soup (why not?) for breakfast.
- Meat and dairy are now occasional indulgences.
On the upside, I figure I’m just leveraging diabetes to make myself healthier.
(Take that, diabetes!)