Do you know that high blood pressure and high cholesterol are among the most frequently diagnosed medical problems in our city? Do you know your blood pressure and cholesterol numbers, and if they are high, are you managing them? In this podcast, Dr. Gary Balady, joins the show to share his best advice on the role of diet, exercise and medications in cholesterol and blood pressure management. This information is vital to know not only during heart month, but all year round!
Gary J. Balady, MD
Dr. Balady is a Professor of Medicine and an Assistant Dean of Admissions at Boston University School of Medicine, and is the Director of Preventive Cardiology and Director of the Non Invasive Cardiovascular Laboratories at Boston Medical Center.
Learn more about Gary J. Balady, MD
Melanie Cole (Host): Did you know that our bodies need cholesterol? Not everybody knows that. It’s in every cell and helps us produce hormones and process vitamin D. However, not every form of cholesterol is good for you, and how do you manage it? What is that even all about? My guest today, is Dr. Gary Balady. He's the Director of Preventative Cardiology and the Noninvasive Cardiovascular Laboratories at Boston Medical Center. Welcome to the show, Dr. Balady. Tell the listeners – let’s start with a little physiology lesson – what is cholesterol? Explain a little bit about the difference between the good and the bad kind.
Dr. Gary Balady (Guest): Sure. Cholesterol is made primarily in the liver, and some of it is absorbed from the food that we eat. Cholesterol is only through animal products, so if we don’t eat any animal products, we won’t get any cholesterol into our system. The rest will be made primarily in our liver. We do need cholesterol for membrane function, nerve function, cell wall membranes, things like that. Sometimes, our bodies make too much cholesterol, and that could be a problem.
Melanie: People get this blood test, and it’s called a lipid panel, and they’re not sure what those numbers mean, tell us what the lipid panel entails and what do those numbers mean?
Dr. Balady: Sure. A lipid panel is generally done with individuals who are fasting, meaning not having eaten for somewhere around ten to twelve hours – so, no eating, no drinking except for some water, perhaps. The numbers will come out in Total Cholesterol, HDL or High-Density Lipoprotein, LDL, which is Low-Density Lipoprotein, and then Triglycerides. Those are the four components of a cholesterol panel.
Melanie: How often should we get it checked?
Dr. Balady: It depends on the level. If the levels are elevated, then we’ll get it checked more frequently depending on what your practitioner wants to do in terms of managing through diet, or through medications, things like that. If your cholesterol panel is within the normal range, then the recommendation is to have it done – in adults 18 years and over, every 5 years.
Melanie: So, if we are looking first to our diet – if we have been told that our cholesterol is a little high, or you don’t really like the numbers, what’s the first line of defense? If we started with diet and then moved on to exercise, tell the listeners what you’d want them to think about when they’re looking at their diet.
Dr. Balady: Sure. The American Heart Association recommends what’s called the heart-healthy diet. The heart-healthy diet has stressed upon it fruits and vegetables, so aim -- we say “strive for five.” Five servings of fruits and/or vegetables every day. That’s not an easy thing to do, and most Americans don’t do that, but it’s something that we should think about throughout our day and try our best to get some fruits in as snacks and vegetables during perhaps, lunch and dinner. Again, strive for five.
If we’re going to eat bread, we’d like to have whole grain bread, so that kind of thing, cereals that are high in fiber, so a high fiber diet with fruits and vegetables. We want to have a handful of nuts every day, and that seems to be helpful to us, two servings of fish per week – not necessarily shellfish, but more of the fatty fishes – and perhaps, one serving of meat per day if one eats meat. That would be fine. And then, limiting sweets in our diet, particularly sugar-sweetened beverages. Those we really want to limit really or completely eliminate if possible.
Melanie: And if we’re looking to exercise to help us to lower our cholesterol, Dr. Balady, how much exercise is enough? How much do we need actually to make a difference?
Dr. Balady: I’m a major proponent of exercise, but one thing about exercise is that it’s actually a myth that exercise is beneficial for cholesterol. It really has a pretty minimal effect on any component of cholesterol. Perhaps, if individuals have high triglycerides because they’re overweight, or have diabetes, in those individuals, exercise can help reduce weight, control blood sugar, and accordingly, will help reduce triglycerides if they are high. Other than that, exercise really doesn’t do much for the other components of cholesterol.
Melanie: So then, there’s medication. People have heard this word “statin,” -- and then they’ve heard those side-effects read very quickly in the commercials – so, what do you tell them about when it’s time for a medicational intervention if the diet doesn’t really make a big difference or there is something genetic going on? What do you tell them about meds, Doc?
Dr. Balady: Diet will help a little bit, but if somebody has really elevated cholesterol, it’s not going to help all that much. At the very best, diet might lower LDL cholesterol – and that’s typically the one that we’re going to pay the most attention to because LDL – Low-Density Lipoprotein Cholesterol is the one that appears to be responsible for plaque buildup in our blood vessels. That’s what we’re hoping to prevent because plaque buildup leads to heart attack, then leads to stroke, and leads to vascular disease and vascular problems, so that’s the whole idea of controlling the cholesterol. It’s not just a number; it’s something that we should pay attention to in order to prevent heart attacks, stroke, and vascular disease.
If an individual needs a statin – your practitioner will calculate what your overall, 10-year risk of developing heart disease, stroke, or vascular disease over the next 10 years. There are calculators that are out there, the most common one that’s used has been developed by the American College of Cardiology, and the American Heart Association. It’s called the ASCVD At-Risk Calculator. I think anybody can actually go online or go to the American Heart Association website and calculate their own 10-year risk. Basically, the components of that risk calculator have to do with age, gender, cholesterol level, blood pressure, and whether or not an individual is a smoker.
Based on all of that information, this calculator will predict what the 10-year risk for developing a cardiac event is. If the 10-year risk is 5% or more, generally, your practitioner will likely recommend medical therapy to lower your cholesterol. It really takes a lot of input and dialogue with the patient to decide have we tried diet enough? Have we tried other kinds of components enough? And then, should we begin to use a statin, so what is the risk and what is the benefit?
The risk of statins is generally very, very low. We hear about muscle aches and liver problems with statins, but those are very, very infrequent. The chance of developing diabetes again is very, very low. On the highest dose statin, the chance is somewhat increased, but it’s really offset by the benefits that the statin provides. Individuals are sometimes concerned about developing cognitive problems or dementia from using statins, but there’s really no evidence to support that. Generally, it’s not an issue.
Most people tolerate statins. They’re great medications. There are years, and years, and years – decades, of evidence and thousands, and thousands of patients to demonstrate that statins when used appropriately, prevent heart attack and stroke.
Melanie: Now, Dr. Balady, while we’re not going to have enough time to get into all of the medications for blood pressure, I would like to talk about it a little bit. The numbers that you want people to have – because that has recently changed – and also, diet and exercise have a profound impact on blood pressure.
Dr. Balady: Yeah.
Melanie: Speak about blood pressure a little bit and some of these changes.
Dr. Balady: Sure, absolutely. Normal blood pressure is now defined as less than 120/80 mm Hg. That is considered normal. A blood pressure that is between 120 and 130 is considered elevated blood pressure. Hypertension – actually, the diagnosis of hypertension, which is high blood pressure – is now defined as a blood pressure of 130/80. Stage II hypertension is that of blood pressure of 140/90. The treatment is going to depend on what level of blood pressure the individual has. One reading is generally not enough, so we want to get several readings before we decide to make decisions about medical therapy.
There is a very important role of lifestyle; I think even more important than in treating cholesterol, with hypertension. Exercise is a great modifier of blood pressure, so if individuals exercise for 20 to 60 minutes, three times a week of moderate-intensity exercise, that can really help lower blood pressure and take somebody from being hypertensive to perhaps, just having either elevated blood pressure or normal blood pressure alone. Exercise alone is a really terrific way to help reduce blood pressure.
In terms of diet -- the diet that I talked about with the American Heart Association diet – that one is modeled after a diet called the DASH diet, which is Dietary Approaches to Stop Hypertension. It’s the same kind of thing in terms of increased fruits and vegetables, increased fiber in the diet, a handful of nuts every day, limiting sugar-sweetened beverages and sweets, as well as limiting sodium in the diet. American Heart Association recommends an average of 1,500 mg of sodium a day. The average American consumes between 3,000 to 3,500 mg of sodium per day --
Dr. Balady: Most of us have a lot of work to do to reduce the amount of sodium in our diet. It does take some work, and once you get used to reading food labels, seeing how much sodium is in a serving, and reducing sodium in the diet, you begin to notice that gee, if you eat something that has high salt content, you probably won’t even like it. It will be less palatable for you. Reducing sodium and doing those other things that I mentioned also can help reduce blood pressure, as well. Often times, a combination of diet and exercise will take somebody from needing medications to not needing them at all. Those are the first foundations of treatment for hypertension.
Melanie: Well, we’ll certainly have to have you on for another segment on reading labels because people are definitely not quite sure about what to look for. But wrap it up for us, Dr. Balady. It’s been such amazing information, especially this time – and really, all times of the year. Wrap it up with your best advice about cholesterol, and blood pressure management, and what you want the listeners to know.
Dr. Balady: Sure. I think the most important thing is what the American Heart Association recommends is know your numbers. Visit your practitioner, have your blood pressure checked, also have your cholesterol panel checked, as well. Sit down, and review areas that you are doing well with and areas that might need improvement. We recommend that everybody get out there and become physically active and do the very best you can to modify your diet and move it towards the American Heart Association diet.
Melanie: Thank you so much, Dr. Balady, for being with us today. This is Boston Med Talks with Boston Medical Center. For more information, you can go to BMC.org, that’s BMC.org. This is Melanie Cole. Thanks so much, for listening.