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What High Cholesterol Means for Your Long-Term Ìð¹ÏÊÓƵ
Interviewer: You get your labs back, and you see the words "high cholesterol," and you're wondering: What now? Is it time to change your diet, start exercising, take medication, or all of the above? Today, we're talking about what actually happens after that diagnosis. What is the step-by-step process your doctor follows? What do they do first, and what comes next?
Internal medicine physician and culinary medicine specialist, Dr. Richmond Doxey, from Ìð¹ÏÊÓƵ of Utah Ìð¹ÏÊÓƵ, is going to walk us through how he helps patients bring those numbers down and why the right plan depends on more than just the lab results.
So my very first question is, I kind of want to make this process transparent for people. Do you usually have to have a conversation about what the numbers mean or the health implications of high cholesterol, or do people kind of get that part at this point?
Dr. Doxey: I usually start by discussing what the numbers mean, and really in terms of risk. So if you have, you know, a high LDL and a low HDL and then you have other risk factors, you know, what does that kind of translate to over the next 10, 20, 30 years?
Interviewer: Got it. So that's where the individual in front of you, the numbers could mean something different depending on who's in front of you.
Dr. Doxey: Mm-hmm, yep.
Interviewer: Let's talk about some of the possible health impacts of high cholesterol.
Dr. Doxey: So cholesterol is a fatty acid or kind of a steroid fatty acid that is synthesized by your body, by your liver. Cholesterol is used to make steroids, to make bile acids, to help with digestion, help with hormones. So it has a variety of functions. So it's not a bad thing in and of itself. But when you have too much cholesterol circulating in your system, it can build up in blood vessels and cause narrowing of the highways for your blood, and then you can end up with a higher risk for stroke or a heart attack, as well as other inflammatory illnesses. That's why it matters is because particularly the risk for stroke and heart attack, and heart disease goes up when your cholesterol goes up.
How Doctors Assess Risk and Choose Your First Step
Interviewer: So, what is the starting point with a patient whose labs came back with high cholesterol? Is it lifestyle, or is it something else? What do you do?
Dr. Doxey: Well, my first starting point is to better understand what the patient is doing. So I'll ask the patient about tobacco use, alcohol use, physical activity, and then I take a very detailed dietary history, talk about what they typically eat, how frequently they eat things like legumes and fish and how many fruits and vegetables, who else is in the home, and get an understanding of, yeah, what food looks like for them day in and day out. And from there, then I can say, okay, in your case, your first step is to quit smoking, or in your case, your first step is to start to make some adjustments, modifications to your diet. And depending on how ready the patient is and how far the conversation goes, we can, yeah, start to make either small but consistent steps. In some cases, I've had patients make significant overhauls pretty quickly, and the results are dramatic.
Interviewer: When you do have a discussion with a patient and, like, they're not smoking, you know, the other risk factors that you talked about don't really apply, you know, they're eating actually pretty well, what's the step after that?
Dr. Doxey: Then the step after that, so if we've determined that things are going pretty well, the patients are eating fairly well, and, you know, a lot of the risk factors are reduced, then I'll say, "Well, let's look at your risk." And there are a couple of calculators that we can use to assess the long-term risk of heart attack and stroke. If the calculator shows that there is an intermediate risk, then I will get additional labs or imaging to determine whether a medication is needed or not, or whether we can wait and work on more lifestyle interventions. If the risk is high enough, then we start medications and continue to work on lifestyle interventions, such as physical activity and dietary changes, and sleep, etc.
Interviewer: Is your goal as a physician to just stop at the lifestyle stuff? Is that your ultimate goal, that lifestyle will take care of the issue, and they don't have to move on to medication?
Dr. Doxey: No, my goal is to reduce the patient's risk as far as we can. With whatever we can do.
Interviewer: Whatever tools you have. I think some people have a kind of negative thought of medication, like I'd like to try to avoid medication. And then I would imagine there are also patients who are like, "Just give me the medication," right?
Dr. Doxey: Yep, there are. Yeah, yeah.
What to Expect If You Need Cholesterol-Lowering Medications
Interviewer: Yeah. So, when does medication come into the mix? I mean, a patient comes in, you talk about lifestyle stuff. Would they also leave with medication that same day? Or do you really try to do some lifestyle stuff for a period of time before you get to medication? Or does it vary?
Dr. Doxey: It varies. Yeah, kind of like I was saying. So if someone's risk is really, really high, LDL is, you know, very high, cholesterol is high, and they have other risk factors, like type 2 diabetes or strong family history, then I'll say, "We need to start a medication," and we do. If a patient has low risk, then we say, "Well, let's work on lifestyle factors, and we'll follow up in six months to a year." And if someone's in the middle, then I'll say, "Well, let's work on lifestyle factors and let's get additional information before we make a decision about medications." But in all of those conversations, I talk to my patients about making additional dietary changes, about physical activity, and if they're ready, they walk away with not only a prescription but also a goal of what they're going to work on in their lifestyle in the next, you know, several weeks to months.
Interviewer: Some people might be hesitant to use medication. What are some of the main reasons, if there is hesitancy, that they are hesitant?
Dr. Doxey: Some patients are hesitant because of things they've read in the press, and some are true, some are not. You know, statins are very widely prescribed medications. Those are the main medications we use to lower cholesterol and, more importantly, reduce heart disease risk and stroke risk. And yeah, there are reported side effects, and because they're used so widely, we now have a lot of data on various side effects. And the most common are muscle aches and joint pains. Those tend to get better with time, but not always. There is concern over increased risk for insulin resistance or diabetes. And that's small, but it's there.
And so, yeah, we have a conversation and say, "Well, you know, there are some risks, and I acknowledge it, and it's true." And then we decide, "Well, is the risk worth the benefit you'll derive from this medication?" That's when I will prescribe. If the risk is higher than the benefit, there's no need for medication. But if the benefit is greater than the risk, yeah, we'll start it. And we can maybe start slow, and again start low. Like I'll often say to patients, "Well, let's start with just a low dose, see how you handle it. And then we can gradually work our way up to a therapeutic dose." And that often works very well.
Timeline for Follow-Up and Seeing Results
Interviewer: After that first initial meeting, and you've had the discussion with the patient, and the patient has had the discussion with you, and they leave with their first plan, whether it's just lifestyle, lifestyle and medication, you know, whatever that happens to be, how long until they come back for that first kind of check to see how that's working?
Dr. Doxey: We recommend getting a repeat cholesterol in a month after starting medications, and then sometimes we'll check their enzymes and a few other labs. And if there has been a significant reduction in cholesterol in a month, then we know the medication is working, and we will then check in about three to six months. If a patient walks away with just lifestyle recommendations, then I will typically get a repeat cholesterol in about three months. It takes a little bit longer with most lifestyle changes than with a medication. And then if it's moving in the right direction, we continue. If it's not, we have a conversation and decide what to do next.
Interviewer: I'm starting to understand why having an expert help you is so important, because there's a lot of if-thens, right?
Dr. Doxey: Yes, there are.
Interviewer: There's not a straight path forward for everybody here.
Dr. Doxey: No.
Why Lifestyle Changes Aren't a One-and-Done Fix
Interviewer: So, really, having a guide like yourself is super important. So after, you know, those follow-ups, then, whether it's a month or three months that you run the labs again, then what does the transition to a long-term plan look like?
Dr. Doxey: It's usually pretty seamless. Again, if a patient has risk factors, I'm like, "Well, this is what you're on for the rest of your life." And we monitor your cholesterol once a year. We may monitor other things, watch for side effects. And then, as I have said before, continue to work on lifestyle changes, physical activity, and following a whole food plant-based or Mediterranean diet. And then we watch things and watch for side effects and make adjustments if we need to.
Again, if a patient is on the fence or borderline, and we decide to start a medication, but the risk isn't super high, then I may even say, "Well, let's check it in a year or two. Let's assess your diet. Let's assess your weight, blood pressure, and everything else." And if things look good, we can even trial off sometimes, like I said, if it's kind of the intermediate risk.
So it's a little bit nuanced. But in most cases, once the risk is high enough to start a statin, it is a lifelong commitment with ongoing dietary and lifestyle changes.
How Doctors Track Success and Adjust Over Time
Interviewer: You've mentioned continuing to work on lifestyle multiple times, right? So it's not like after you leave that first time, most people are going to have switched their lifestyle in such a way that, you know, they're going to instantly lower their cholesterol. This is something you have to be kind of mindful of, and you continue to work on and practice the rest of your life, it sounds like.
Dr. Doxey: Yes, correct. Yes. The most dramatic and rapid changes I have seen patients make have been those who have done it before. So I've had patients who have been on either like a totally whole food plant-based diet or the Mediterranean diet, very strictly for years, kind of get off the wagon, cholesterol goes up, weight goes up, and they're like, "Hey doc, I want to make a change. I want medications." I said, "Well, that sounds good. Let's . . ." We walk through it, set goals.
And if a patient has done it before and has the experience, then, yeah, I've seen dramatic reductions in cholesterol and in weight and in heart disease risk within a few months, because the patient is prepared and capable of just making a total overhaul. For most patients, it's a matter of taking a step and then building a new habit, and then layering another habit on top of that, layering another habit on top of that. And with gradual and pretty close follow-up and coaching, again, we can see dramatic changes, but it takes longer, but they'll get there.
Interviewer: Yeah. And I think the other thing to mention is that there's a lot of information that people have to process, what is, you know, a healthy lifestyle? A lot of times, we've never been educated on that sort of thing, right?
Dr. Doxey: Yep, yep.
The Most Important Thing to Remember After a Cholesterol Diagnosis
Interviewer: Is there anything I missed in the process? I think I have a pretty good understanding of kind of the general process, what it might look like. But is there something that I've been blind to, that I should be asking about, that you think a patient would find helpful?
Dr. Doxey: Well, I think the other thing to realize is we follow numbers. We have targets for lowering the LDL, the "bad cholesterol," and that's why we recheck labs, so we can see if the dose you're on or if the lifestyle changes you've made are sufficient, then we continue it. And if we're not there, then we'll increase the dose of medication or, in some cases, add another medication to get the LDL, the "bad cholesterol," down to the desired range, again, depending on your risk.
So this is a dynamic process. You know, in some cases, you get to the point where you're on a steady dose, and it's working, and you just kind of stay that way for years. But certainly initially, in the first year or two, we may make significant adjustments until we find the right combination or dose.
Interviewer: As we wrap up here, for somebody listening who just found out they have high cholesterol, what is the big picture you want them to understand about how doctors approach it and what's actually possible?
Dr. Doxey: I think the main point is that change is possible. Like you can make significant enough changes to your lifestyle, in almost every case, to make a significant reduction in your heart disease risk with or without medications. Sometimes you need a little help, but lifestyle changes will make the difference in your risk and in how you feel. And the only side effects are good ones, to borrow the tagline from Dean Ornish.