Infectious Diseases

A new study shows that despite the fact that
cholesterol-lowering medications can lower the risk of heart attacks and death
in people with heart disease, many physicians at major teaching hospitals still
do not prescribe them. The study, undertaken by researchers from several
leading universities, also found that significantly fewer women than men with
heart disease are receiving any medication at all. The study was published in
the Feb. 14 issue of the Archives of Internal Medicine.

“In general, treatment rates for patients with a history of heart
disease were far too low, but the lack of adequate treatment in women was
particularly worrisome,” writes lead author Michael Miller, MD, director of
preventive cardiology at the University of Maryland Medical Center and
colleagues from elsewhere. “These results provide evidence of considerable
sex bias in the treatment of women with heart disease at major academic medical
centers.” Miller is also associate professor of medicine at the University
of Maryland School of Medicine.

The study investigated the use of cholesterol-lowering medications in more
than 800 men and women with heart disease at 16 academic medical centers in the
U.S. and Canada. Twenty percent of the study participants were women.
Researchers found that about half of the patients had dangerously high levels
of LDL, the “bad” form of cholesterol, above 130 mg/dL.

According to the National Cholesterol Education Program guidelines, the LDL
goal in heart disease patients should be below 100 mg/dL. Patients with an LDL
that exceeds 130 mg/dL will generally require medication, as will people who
continue to have an LDL greater than 100 mg/dL even after making dietary
changes.  

Researchers found that in 1994, a little more than one-third of women and
men with high LDL were receiving cholesterol-lowering medication. By 1997,
however, more than half of the men were receiving medication, while only
one-third of women were receiving drug therapy. Not surprising, scientists also
learned that women were much less successful than men in reaching acceptable
LDL levels.

Researchers did not know why women were so under-treated compared to men,
especially since the extent of heart disease was similar in both groups.

“We have great knowledge and proven therapies to reduce the risk of
first and second [heart attacks],” Miller tells WebMD. “We also have
great [study results] to show that we can reduce the risk of heart disease.
[Now,] we need to take better advantage of these [resources.]“

Other experts say that patients also need to take responsibility for their
health. Dick Karas, MD, PhD, director of the Women’s Heart Center at New
England Medical Center in Boston, says it’s important for patients to know
their cholesterol levels and keep track of changes. “Ask your doctor what
it is, and write it down,” he tells WebMD.

which is best known for causing genital warts greatly increases the chance that a woman will get cervical cancer in the coming years. The risk is greatest when a woman’s body is unable to get rid of the virus over the course of many years.

“Women need to know that this is a really serious cancer risk,” Robert Burk, MD, tells WebMD. Burk, a professor at Albert Einstein Medical College in New York and the author of an editorial accompanying the Swedish study, says that women with long-term infections need to be monitored closely, and to have any growths of abnormal cells removed. But he says that short-term infections, which are very common, do not pose a significant threat.

HPV is transmitted primarily through sexual intercourse and is one of the most common sexually transmitted diseases. There are more than 30 types of HPV, but only a few seem to play a major role in cancer by allowing the growth of abnormal cells.

The Swedish team, from the Karolinska Institute in Stockholm, compared old Pap smears from about 120 women who developed cervical cancer with Pap smears from an equal number of healthy women of the same age. The researchers found evidence of HPV infection in 30% of the old smears from women who went on to develop cancer, compared with just 3% of smears from women who remained healthy. On average, cancer was detected more than five years after there was evidence of an HPV infection.

Because most women who get HPV infection clear the virus from their body within a few months, the scientists wanted to know whether that was also true of women who got cancer. It wasn’t. DNA tests revealed that the same type of HPV found in old Pap smears was present in cancerous cells removed from the cervix years later.

“It’s persistent infections that are the problem,” Burk says. Persistent means an infection that is present for at least a year. Doctors can detect such infections by sending samples of cells to labs that perform DNA tests to determine the type of HPV.

But Burk says that such testing is probably not a good idea for most sexually active young women because so many of them are infected with HPV and because only about 20% have infections that last more than a year. In older women, he says, repeated DNA testing may be a valuable way to find those who should be monitored closely for early signs of cervical cancer.

High cholesterol especially too much LDL-C, the so-called bad cholesterol is a known risk factor for heart disease, but a new study suggests that most people who are treated for high cholesterol fail to lower it enough to meet target levels.

Researchers from the study, called the Lipid Treatment Assessment Project (L-TAP), say that only 38% of the 4,888 people they studied achieved their goal cholesterol levels. This is a troubling finding, they suggest, since the study was designed to track the effectiveness of treatments by physicians in the community. When researchers test drugs in the controlled environment of clinical trials, the results are often impressive, but critics maintain that those results may not be reproducible in the everyday clinical setting.

“I think it’s an educational thing. We’ve just got to keep educating doctors,” Joseph S. Alpert, MD, tells WebMD. “It just takes time to get people to do it. We have the same problem with other diseases.” Alpert, who heads the department of medicine at the University of Arizona Health Sciences Center, was not involved in the study.

The researchers, led by Thomas A. Pearson, MD, PhD, of the University of Rochester School of Medicine, had the same concern. Writing in the Archives of Internal Medicine, they conclude that more aggressive treatment of high cholesterol is needed to reach the goals established in guidelines set by the National Cholesterol Education Program (NCEP).

The study supported by a research grant from the Parke-Davis pharmaceutical company of Morris Plains, N.J., looked at patients who were undergoing treatment by 619 primary care physicians. The patients, aged 20-75, were treated with either lipid-lowering drug therapy or diet. Investigators divided patients into three groups: Low-risk patients, who had no evidence of coronary heart disease (CHD) and fewer than two risk factors for it; high-risk patients, with two or more risk factors and no evidence of heart disease; and patients who actually had heart disease. Risk factors included age (45 or older for men and 55 or older for women), family history of heart disease, cigarette smoking, hypertension, and diabetes.

Only 38.4% of patients in the study achieved their target levels of LDL-C. The success rate was highest among the low-risk group (68%), followed by patients in the high-risk group (37%), and was lowest among patients with CHD (18%), the researchers write. Among those in the high-risk group, the more risk factors a patient had, the more successful treatment was.

“When you have an effective therapy, those who are most severely affected are going to benefit the most,” Alpert says.

Another finding was the link between diet and success. Although only 34% of the 751 patients who were treated with diet instead of drug therapy achieved the target LDL-C level, “compliance with diet still contributed to LDL-C lowering and remained a significant predictor of success,” the researchers write. This could be interpreted to mean that patients who comply with diet guidelines might also be more compliant with medication, they say.

The all-American boy or girl of the 21st century is a couch potato, and many already have both high blood pressure and high cholesterol, say researchers who study heart disease in children.

Studies presented at an American Heart Association meeting here report that 18% of children between the ages of 1 and 16 have either high cholesterol or too little of the so-called good cholesterol, or HDL. Those figures are alarming, but the numbers are even worse in the Appalachian area of West Virginia, where heart disease is epidemic. In West Virginia about 40% of children in one study were overweight and 20% had high cholesterol.

West Virginia has been identified as “as one of the regional pockets of heart disease,” says William Neal, MD, of West Virginia University in Morgantown. Neal and Ellen Demerath, PhD, assistant professor at Wright State University School of Medicine in Kettering, Ohio, have been trying to determine just how early heart disease starts among West Virginia residents. They decided to study fifth graders because they have not yet entered puberty, an age at which normal hormone changes have an effect on weight and cholesterol. Thus far, they have completed a study of more than 300 fifth graders. In that work, they found that 20% of the children had total cholesterol above 200, which is considered high, 18% had high blood pressure, and 60% were exposed to tobacco in their homes.

Demerath says these children were significantly more obese than a group of Ohio children who are very similar in that most of them are “poor and white.” On average, the West Virginia children were about 15 to 17 pounds heavier.

Neal says the finding is particularly disturbing because most of the children with high cholesterol would not be identified for screening using the National Cholesterol Education Program (NCEP) guidelines. Those guidelines say that children should be tested for high cholesterol if their parents have total cholesterol above 240, have a family history of heart attack in a relative younger than age 55, or if the parents’ cholesterol is unknown. Among the West Virginia children, only 24% had a family history of early heart disease, says Demerath.

Darwin Labarthe, MD, PhD, says the NCEP is scheduled to review the current screening guidelines. “We expect new guidelines in about 18 months or so,” he says. Labarthe chaired a press conference that focused on early indications of heart disease. He is with the National Center for Chronic Disease Prevention and Health Promotion at the CDC.

Taken as a whole, the news on children isn’t encouraging, Labarthe tells WebMD. He says there appears to be “an epidemic of obesity, high blood pressure, [high cholesterol], and diabetes. The picture that we have of our children’s health is not a good picture. The direction of change that we are seeing in childhood is not good.”

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Adding to the ever-growing list of potential uses for the powerful and ubiquitous cholesterol-lowering drugs called statins two new studies presented here suggest that the drugs, when given early after a heart attack, can significantly reduce the risk of death. Yet ironically, despite the overwhelming evidence supporting their use, doctors and patients alike seem to be slow in getting the message.

“Despite five huge [studies looking at the statin drugs], all of which were consistently positive … we still think that only about half the people who could benefit from statin therapy are receiving it,” says Antonio Gotto, MD, dean of the Weill Medical College of Cornell University in New York. These studies showed that cholesterol lowering with statin therapy reduced risk of death, heart attack, and a number of other cardiac events when given to patients at high risk of heart disease, such as those who have diabetes or high cholesterol, or who have suffered a previous heart attack.

Among the new studies presented here Tuesday at a meeting of the American College of Cardiology, one looked at 3,700 patients who had either a threatened or actual heart attack; one-third had received cholesterol-lowering therapy during their hospitalization. The researchers found that, at 30 days after hospital discharge, there was a dramatic difference in the death rates between the group that got the medication and those who didn’t. After six months, the numbers were even more impressive: The death rate in the group that got statin therapy was 60% less than in those who didn’t get the drugs.

The lead author of the study, Herbert Aronow, MD, MPH, of the Cleveland Clinic Foundation, cautions that the findings aren’t definitive, but he calls the reduction in death “tremendous.” He believes that the studies are an indication that cholesterol-lowering therapy given early after a heart attack could become the standard care for heart attack patients.

Currently, there is no standard. Patients with heart attacks sometimes are given cholesterol-lowering therapy days to weeks after their diagnosis.

Gotto, a pioneer in cholesterol research, says that the findings provide preliminary proof that statins do a lot more than lower cholesterol levels. Some previous studies show that statins may actually inhibit hardening of the arteries, or atherosclerosis, which is implicated in causing heart attacks, he tells WebMD.

Another study presented here shows that doctors are recommending statin drugs for their heart attack patients but not as much as public health officials would like. Older patients and women are less likely to get the medicines than others, according to the research.

“It takes awhile to change habits,” says lead study researcher Cynthia Jackevicius, MSc, of Toronto General Hospital. But, she adds, people seem to be more willing to take supplements to prevent disease than proven prescription medications.

Gotto agrees. He suggests that over-the-counter statin therapy or even cheaper statin drugs may be the answer.

In addition, Gotto says that the public is rather complacent when it comes to heart disease. “People are just not as frightened of heart attacks as they are of … cancer,” he says. “If a drug could lower cancer risk by 25-30%, people would run out to get it.”

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People concerned about their cholesterol levels
no longer have to pass on pecans. Researchers at New Mexico State University
have discovered that gobbling down as much as two fistfuls per day of the
smooth, oblong nut can lower low-density lipoprotein (LDL) the ‘bad’
cholesterol linked to heart disease.

“We discovered that pecans can have a place in a healthy diet,” lead
researcher Wanda A. Morgan, PhD, RD, tells WebMD. “Pecans, in balance and
moderation with other foods, can help protect us against heart disease.”
The study appears in the March 2000 issue of the Journal of the American
Dietetic Association. The Western Pecan Growers Association funded the
study.

According to the National Institute of Health (NIH), a high level of
LDL-cholesterol in the blood increases the risk of fatty deposits forming in
the arteries, which in turn increases the risk of a heart attack. Thus,
LDL-cholesterol has been dubbed ‘bad’ cholesterol. At the same time, an
elevated level of high-density lipoprotein HDL or ‘good’ cholesterol
seems to have a protective effect against heart disease.

In the pecan study, 19 participants roughly three quarters female with
normal cholesterol levels were divided into a pecan eating group and a control
group. The nut eaters ate 88 grams of shelled pecan halves per day for eight
weeks. They could choose whether to eat their daily pecan rations as snacks or
as part of their regular meals. The pecan eaters were prohibited from eating
other nuts, and people in the control group were not allowed to eat any nuts at
all. Blood samples to check cholesterol levels were taken at the beginning of
the study and at four- and eight-week intervals.

After the first four weeks of the study researchers found the pecan eaters’
LDL cholesterol lowered by 10%, although after eight weeks, it was only down 6%
from its original level. Morgan says unlike other studies on nuts, participants
were allowed to choose what they ate, instead of following a restricted diet.
“We wanted to mimic as much as we could what people really did with their
daily meals to see if we could still get some of the benefits that were showing
up with the other studies,” says Morgan, who is an associate professor in
the department of family and consumer sciences at New Mexico State University
in Las Cruces.

The pecan research is the latest positive study on the benefits of the
much-maligned family of tree nuts. In 1999, French researchers reported that
people in the Dauphine region of France who frequently consumed walnuts or
walnut oil typically used in salad dressings had higher levels of
HDL-cholesterol and another helpful factor associated with cholesterol than
did people who never ate walnuts.

Building on previous medical research finding
a link between low cholesterol levels and violent death, notably suicide, a new
study shows that men with relatively low cholesterol levels were up to seven
times more likely to report symptoms of severe depression.

“Studies looking at the relationship between cholesterol level and
depressive symptoms are scarce,” says Diederick Grobbee, MD, PhD, co-author
of the study, in a press release. “Because there has been so little
research in this area, the reasons why low cholesterol influences the
occurrence of depressive symptoms are unknown. This study provides further
evidence that there is a relationship and reinforces the need to look at the
reasons for the relationship.” Grobbee is chair of the Julius Center for
Patient Oriented Research at University Medical Center in Utrecht,
Netherlands.

Grobbee and colleagues found that 130 men with total cholesterol levels less
than 175 over a four-year period were four to seven times more likely to have
symptoms of severe depression, compared with men with cholesterol levels of 230
to 270. No association was seen between cholesterol levels and anger or
hostility. Recent weight loss and lower caloric intake were also associated
with depression.

“This may be an important finding in the ongoing debate concerning the
putative association between low cholesterol levels and death due to violent
causes. Future studies are needed to reveal the mechanisms of this increased
risk and to demonstrate its causal association with chronically low cholesterol
levels,” write Grobbee and colleagues.

Edward Suarez, PhD, who was not involved in the study, tells WebMD that he
has also done research supporting a link between some component of blood fats,
such as cholesterol or triglycerides, and depression and anxiety. He is
assistant professor of medical psychology at Duke University Medical Center in
Durham, N.C. “I think that at some point, measurement of cholesterol and
the cholesterol profile may be used as a screening tool for depression,”
says Suarez.

According to a recent study, men who have relatively low levels of
cholesterol are four to seven times more likely to report symptoms of severe
depression than men with high cholesterol levels.
Although there have been a few studies showing this relationship between
cholesterol and depression, scientists are still unsure how to explain this
association.
Other attributes associated with depression in this study were recent
weight loss and low caloric intake.

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Having a normal cholesterol level does not mean
having no danger of heart disease, according to a new study. Researchers say
nearly half of the patients they studied who underwent heart bypass surgery had
cholesterol levels considered normal (under 200).

“Some of the patients who needed bypass surgery had cholesterol levels
below 100,” researcher Fred Kummerow, PhD, tells WebMD. “So we really
can’t depend on serum cholesterol as an indicator of heart disease.”

But Kummerow says that a proper diet remains important in preventing heart
disease particularly one that is low in the hydrogenated fats often found in
processed foods. Kummerow, whose work was published in the journal
Atherosclerosis, is professor emeritus of food sciences at the
University of Illinois at Urbana-Champaign.

Kummerow and fellow researchers studied 1,200 men and women and found that
almost two-thirds had artery blockages significant enough to require bypass
surgery. Almost 50% of those who underwent heart surgery had cholesterol levels
of less than 200. For this reason, Kummerow says, cholesterol may not be the
best indicator of heart health.

“Still, there’s no question that a well-balanced diet is important in
preventing heart disease,” says Kummerow. “And fat intake is a question
of how much and how often. Rather than eliminating meat and dairy products,
it’s probably more important to reduce intake of hydrogenated fat. It’s often
very high in processed foods, and includes soybean, palm, and coconut
oils.”

Kummerow says that eating more fruits and vegetables is an excellent
approach, and dieticians agree.

“The idea is to substitute foods that are high in fat with fruits,
vegetables, and whole grains,” says Cindy Moore, MS, RD, director of
nutritional therapy at the Cleveland Clinic and a spokesperson for the American
Dietetic Association. “But we need meat for muscle mass and dairy products
for strong bones and teeth. Fortunately, we can get the nutrients with smaller
meat portions and low-fat dairy products.”

Even small changes can make a big difference, experts say.

“Moderate changes in diet and activity have a major effect on
health,” says James Anderson, MD, “Just walking a mile per day reduces
the risk of heart attack, stroke, and cancer by more than 50%.” Anderson is
an endocrinologist at the VA Medical Center in Lexington and a professor of
clinical nutrition at the University of Kentucky School of Medicine.

Kummerow, 85, definitely practices what he preaches. He plans to continue
swimming and weight training six times a week. His cholesterol is 220

Vital Information:

Having a normal cholesterol level does not mean someone is in no danger of
heart disease.
In a recent study, up to half of those who underwent heart bypass surgery
had cholesterol levels below 200, and some patients’ levels were below
100.
Researchers say exercise and diet are still very important. Everyone should
try to eat fruits, vegetables, and whole grains and limit the intake of fats
found in processed foods.

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Add the macadamia to the growing list of healthy nuts. A
study from the University of Hawaii shows that a diet containing the high-fat
nuts can actually improve cholesterol levels.

“The conventional wisdom still is that macadamia nuts are so good that
they must be bad for you,” says Curb. “This study indicates that its
preconception is not true and that macadamia nuts can actually be part of a
healthy diet,” lead researcher J. David Curb, tells WebMD. Curb is a
professor of geriatric medicine and clinical epidemiology at the University of
Hawaii School of Medicine and chief of the Division of Clinical Epidemiology in
Honolulu. Similar benefits have also been reported with walnuts, almonds, and
pecans.

“Macadamia nuts have a bad reputation for having a lot of fat, but our
research shows the fats they contain, especially monounsaturated fatty acids,
don’t adversely impact cholesterol,” he says.

One ounce of macadamia nuts contains 20.9 grams of fat per once, and 88% of
the calories come from fat, according to the U.S. Department of Agriculture. By
comparison, pecans contain 19.2 grams of fat, almonds contain 14.8, walnuts
contain 17.6, and peanuts contain 13.8 grams of fat per ounce.

Researchers in the new study, which appears in the April 24 issue of the
journal Archives of Internal Medicine, compared three diets. One diet,
classified as a “typical American” diet, contained 37 percent of
calories from fat. The second diet was similar but with the fat calories
derived from macadamia nuts. The third was the American Heart Association’s
“prudent diet,” with 30% of the calories from fat. In the study, 15 men
and 15 women, 18-59 years old, ate each of the three diets for four weeks.
Calories were adjusted to maintain constant weight levels, and menus contained
common local foods. All meals were prepared and eaten in the college
cafeteria.

Blood fat analysis showed cholesterol levels after the macadamia nut diet
were similar to the low-fat diet and lower than the typical American diet. The
macadamia nut diet produced lower levels of triglycerides, an important form of
blood fat, than either of the other diets. Despite an increase in the
proportion of fat in their diets, volunteers showed no significant change in
weight or cholesterol levels.

Researchers saw no negative side effects from eating the macadamia nuts,
and, according to Curb, these results were similar to findings from an earlier
study he conducted in which volunteers ate a diet containing large quantities
of ground macadamia nuts for one month.

Curb says macadamia nuts are high in oleic acid, a monounsaturated fatty
acid also found in olive oil and canola oil, which is believed to be beneficial
in cutting cholesterol. Also, the nuts are the only food to also contain
significant amounts of palmitoleic acid, another monounsaturated fatty
acid.

Using a new type of margarine lowers cholesterol in healthy
children and gives them a head start on avoiding the life-long process of
developing heart disease, according to a study from Finland that appears in the
April issue of The Journal of Pediatrics.

In addition, the investigators find that this new spread, called plant
stanol ester margarine but sold as Benecol, has no bad side effects in the
short run for healthy children who already consume a low-saturated-fat,
low-cholesterol diet.

The margarine is derived from pine tree wood pulp and works by blocking the
absorption of cholesterol in the gastrointestinal tract.

“Finland is a country with a high death rate from [heart] disease,”
Anne Tammi, MD, tells WebMD. “Most children in our country have
[cholesterol levels] much higher than recommended. We wanted to study whether
plant stanol margarine would further decrease ? cholesterol in healthy children
who had been on a diet low in saturated fat and cholesterol for years.”
Tammi is a researcher at the University of Turku in Finland and one of the
study’s investigators.

“There is a consensus today that [heart] disease has it roots in very
early childhood,” Alpo Vuorio, MD, tells Web MD. “The take-home message
here is that stanol ester spread offers an effective and safe way to lower
[overall] cholesterol and LDL (the “bad” cholesterol) without side
effects.” Vuorio, a University of Helsinki researcher, led an earlier study
on the new margarine.

The 72 children who completed this latest study also are participants in
another trial in Finland that is looking at whether children will avoid
developing heart disease if they watch their diet from birth. In the study,
each day for three months they replaced their regular margarines with 20 grams
of the stanol ester spread. To put that in perspective, there are eight grams
of stanol ester in one and a half teaspoons.

Blood tests to measure the total cholesterol, LDL “bad” cholesterol
and HDL “good” cholesterol, were taken before and after the study.

Using the stanol ester margarine decreased the total cholesterol over 5% and
decreased “bad” cholesterol by over 7%. Although the HDL did not
change, the effect was still positive, because ratio to total cholesterol count
increased.

Should parents include stanol ester margarine in the diet of a healthy
child?

“[For now], we are encouraging parents to supply their children with a
diet low in saturated fats and cholesterol,” Tammi says. “This provides
a cholesterol reduction of about 5% to 10% if constantly followed.”

Linda Van Horn, PhD, a preventive medicine expert at Northwestern University
who was not involved in the study, agrees.

“Try diet first,” she tells WebMD. “That means less than 30% fat
and less than 10% saturated fat. If the child is not adhering to a low-fat
diet, then you might add plant stanol ester margarine with the supervision of a
health professional. Parents shouldn’t think that you can give a child a stanol
ester and all the cholesterol problems will melt away.”