Prescribing Lower Cholesterol: Describing the different types of cholesterol-lowering medicines, Evaluating the risks and benefits of prescription products, Deciding who should take an anti-cholesterol drug and Remembering other ways to control cholesterol.

Prescribing Lower Cholesterol

In This Chapter

� Describing the different types of cholesterol-lowering medicines

� Evaluating the risks and benefits of prescription products

� Deciding who should take an anti-cholesterol drug

� Remembering other ways to control cholesterol

Okay, so you’ve changed your diet to conform to the guidelines in Chapters 4 and 5, you’ve stepped up your exercise (see Chapter 8), and you’ve

lost a couple of pounds — maybe even more than a couple of pounds. But — can it be? — your cholesterol levels are still higher than your doctor considers healthy. What to do?

You may be a candidate for cholesterol-lowering drugs. This chapter, with eight tables and one very detailed drawing of your innards, compares the effectiveness of different kinds of drugs, explains the unfamiliar words used to name these drugs, lists potential side effects, and generally gives you the facts you need to make an informed decision as to whether you’re a candidate for cholesterol-busting meds. So read it.

Introducing Cholesterol-Lowering Medicines

Modern medicine has reduced the number of deaths from heart attacks, but, until recently, it hadn’t substantially lowered the number of heart attacks or cases of heart disease. One possible way to accomplish this is to eliminate the cause of many heart attacks — that is, to lower the amount of cholesterol swimming around in the blood.

Doctors currently use one (or more) of four different kinds of meds to lower cholesterol, which I list here:

� Statin drugs

� Cholesterol blockers

� Bile acid sequestrants

� Triglyceride inhibitors (including the B vitamin niacin)

To explain the particulars about these meds, I have created a separate section for each starting right after the nifty picture of your insides in Figure 12-1, which shows where in your body the cholesterol-lowering drugs do their good work.

Patients with high cholesterol (particularly those who’ve already had a heart attack) may also be given anticoagulants (blood thinners) such as aspirin and clopidogrel (Plavix). Anticoagulants don’t lower cholesterol, but they do reduce the risk of blood clots, thus reducing the risk that a blood clot gets stuck in a cholesterol-clogged artery.

Cutting cholesterol off at the source: Statins

Atorvastatin (Lipitor), fluvastatin (Lescol), pravastatin (Pravachol), simvastatin (Zocor), and rosuvastatin (Crestor) are medicines known collectively as “statins.” The statins reduce the body’s synthesis of cholesterol, which means they are definitely heart-healthy. In fact, the usual dozens of studies cited in cases like this show that taking a statin drug can do all these good things:

� Lower your LDLs

� Raise your HDLs

� Reduce your plaque (the technical term for gunk sticking to your artery walls that may break off and form clots, which can block the flow of blood and cause a heart attack)

� Protect the lining of your arteries

All arteries are lined with tissue called endothelium. When the endothelium doesn’t function properly, the artery starts to build up plaque. Statins, as well as some other drugs, keep the endothelium healthy — another way these drugs lower your risk of heart attack or stroke.

� Lower your C-reactive protein, another risk factor for heart attack that you can check out in Chapter 3

� Reduce your risk of a first heart attack

� Reduce your risk of a second heart attack if you’ve already had one

� Reduce your risk of stroke

Statins are sold as single ingredient pills or combo pills that add a second heart-healthy drug such as one that lowers blood pressure. Table 12-1 lists the various statin products currently on your drugstore shelf or behind the counter.

Statin side effects

Because you’re reading this book, I know that you’re an informed medical consumer. Because you’re an informed medical consumer, you know that even beneficial medicines may pose problems for some patients.

When statins first came on the market, manufacturers included a notice in the small print of their product information about muscle cramps, aches, pain, and weakness, but it sure looked insignificant. Yet from their introduction in the late 1980s, it was clear that statins may trigger rhabdomyolysis, an excessive breakdown of muscle tissue creating a flood of waste cells that tumble through the bloodstream and into the kidneys where they may clog small passages and — theoretically — cause kidney failure.

Until the summer of 2001, the word theoretically was very, very important. In clinical trials of more than 50,000 patients, researchers hadn’t linked a single death to statin-triggered kidney failure. But cerivastatin (Baycol), a new statin introduced by Bayer A.G. in 1997, was different. The incidence of rhabdomyoly- sis among Baycol users was about ten times higher than among people taking other statin drugs, and the reaction was more likely to be really serious — read: fatal.

Name games

When the words on this page move from unfa- miliar to incomprehensible, you know you’re into the serious stuff. That’s the case with HMG- CoA reductase inhibitors, the scientifically- correct name for statins.

The easy way to define HMG-CoA reductase inhibitors is to work backwards, starting with the last word in the name. Inhibitor is plain English for something that keeps something else from doing something.

Now, move back one word to reductase. Note the ending -ase, which is the scientific short- hand for enzyme. Now you know an HMG-CoA reductase inhibitor is a drug that interferes with (inhibits) the action of an enzyme. Hey, that’s not bad for a non-scientist!

Next step: CoA. The initials stand for coenzyme A. But if you look that term up in Stedman’s Medical Dictionary, the one most science writers use, it directs you to HMG-CoA, the abbreviation for — take a deep breath — beta-hydroxy-beta- methyl-glutaryl-CoA.

What in the world is beta-hy. . . . No, no, not again. I’m going to stick to the abbreviation. HMG-CoA is an important player in converting fats to lipoproteins and cholesterol.

Put it all together, filter out the science speak (well, most of it), and you get the plain-language definition of an HMG-CoA reductase inhibitor: A drug that reduces the activity of an enzyme needed to turn fats into lipoproteins and cho- lesterol, especially the nasty little LDLs.

Wait. Don’t leave. I’m not done.

The generic names for all HMG-CoA reductase inhibitors end in –statin because, as the International Union of Pure and Applied Chemistry and the International Union of Biochemistry and Molecular Biology so care- fully note, the suffix –statin stands for “factors inhibiting the release (and perhaps the synthe- sis) of pituitary hormones.”

Now we’re done. Whew.

By August 7, 2001, when Bayer took Baycol off the market, at least 31 deaths had been linked to the medication in the United States, and the Food and Drug Administration (FDA) had reports of nine more deaths abroad. The total number of deaths linked to Baycol has never been finalized, but the esti- mated number of cases of rhabdomyolysis eventually rose into the thousands, and according to the Kaiser Daily Health Policy Report of November 23, 2004, Bayer has settled nearly 3,000 lawsuits about Baycol-related injuries.

Today, the package inserts and advertising for all statin drugs include a warning about muscle pain, usually like this in bold black type. Forewarned, after all, is forearmed. The following list details the currently recognized side effects of statin drugs:

� Common side effects: Abnormal results on tests for liver enzymes (temporary), allergic rash, fatigue, headache and dizziness, low blood pressure, upset stomach (nausea, gas, diarrhea, or constipation)

� Less common/potentially serious side effects: Persistent abnormal results on liver function test, accompanied by hepatitis, abnormally low platelets (particles that enable blood to clot), emotional depression, memory loss, muscle pain and tenderness, muscle loss (rhabdomyolysis), protein in the urine

Naturally, because you are, as noted above, an informed medical consumer, you tell your doctor right away if you experience any of the more serious side effects. Right away. No waiting. Really.

Statin interactions with other drugs

If you take a statin along with a drug that blocks the action of liver enzymes required to eliminate statins from your body, the level of statins floating about your organs and tissues may rise high enough to cause serious muscle damage — and maybe even kidney failure — which isn’t a good thing. Among the drugs known to hit those liver enzymes and trigger this reaction are the antibiotics clarithromycin (Biaxin) and erythromycin; oral fungus fighters, such as keto- conazole and other meds whose names end in –azole; and protease inhibitors (HIV/AIDS drugs).

Taking two or more meds at once is a balancing act, so always tell your doctor exactly what you’re taking when she prescribes a new medicine, including a statin.

Nature’s cholesterol busters: Not

Hate doctors? Don’t want to spend all your money on prescription drugs? Think you can find an inexpensive over-the-counter cholesterol buster? Fuggeddabboudit.

In the late 1980s, health food stores did a nifty business selling a “natural” cholesterol buster called Cholestin. The active ingredient in Cholestin was red yeast rice (or red rice yeast) produced by fermenting a particular strain of rice with — what else? — yeast, a process that created a form of lovastatin, the statin drug sold under the brand name Mevacor.

Because red yeast rice was introduced as a dietary supplement, not a drug, it didn’t have to go through the rigorous tests for safety and effectiveness required of lovastatin. Was it safe? Probably as safe as lovastatin. Did that mean perfectly harmless? Clearly not, as you can see for yourself by reading the side effects listed for lovastatin earlier in this chapter.

In 2000, the 10th U.S. Circuit Court of Appeals ruled that red yeast rice was a drug and therefore subject to regulation by the Food and Drug Administration (FDA). After that, the FDA went all out after any company selling red yeast rice, demanding to see proof — real scientific studies, please — demonstrating the safety and effectiveness of any product containing red yeast rice.

As an inevitable result, while products listing red yeast rice as an ingredient are still available on health food and drugstore shelves, the rice is made differ- ently and no longer contains any statin. Other “natural” cholesterol-lowering products may contain various herbs, vitamins, dietary fiber, and plant compounds such as stanols and sterols (the anti-cholesterol ingredients in some margarines described in Chapter 6). You don’t need a prescription for these products and the packages sure are pretty, but none of them will lower cholesterol as effectively as statin drugs.

Trading bile for cholesterol: Bile acid sequestrants

Right off the bat, here are a couple of those unfamiliar words I mentioned at the start of this chapter. Don’t panic. Just take ’em one at a time. Bile acids are digestive aids stored in your gallbladder. (If your gallbladder has been removed, your body still makes bile acids but releases them into the digestive tract instead of storing them.)

Bile acids enable you to metabolize fats so that your body can absorb fatty acids (no, ice cream doesn’t go straight from your lips to your hips) and convert them to useful products such as — you got it — cholesterol. Bile acid sequestrants are compounds that grab up bile acids in your intestines and eliminate them via your feces before the bile acids can do their job on fats.

You take bile acid sequestrants right before you eat so they’re readily available when the gallbladder begins to release bile acids for digestion. As the bile acid sequestrants grab up so much bile acid that you can’t efficiently digest fats, your body says, “Whoa there! I need some more of this stuff.” As a result, you begin to convert some of the cholesterol in your body to bile acids to replace the ones you’ve mopped up and eliminated, and the amount of cholesterol and triglycerides in your blood goes down.

The different bile acid sequestrants

The most commonly used bile acid sequestrants, listed in alphabetical order by their generic names, are

� Cholestyramine: Available either as a powder to mix with a clear liquid, such as water or juice, or as a chewable bar. The brand names for cholestyramine are Prevalite and Questran.

� Colesevelam: Available in tablet form — a unique selling point. The brand name for colesevelam is Welchol.

� Colestipol: Available as coated tablets, flavored granules, a liquid, or in packets of powder (to be dissolved in water). The brand names for colestipol are Colestid and Lestid.

Taking low doses of bile sequestrants (8 gram/day) may knock cholesterol levels down by 10 to 15 percent. Tripling the dose may lower LDL levels by 25 percent.

Taking bile sequestrants with a second drug improves their performance. For example, in one drug trial, taking colesevelam alone cut total cholesterol by about 10 percent and LDLs by about 18 percent. Taking colesevelam plus a statin drug cut total cholesterol up to 21 percent and LDLs up to 32 percent.

The side effects of bile acid sequestrants

Bile acid sequestrants have been in use for so long that their overall long-term safety is well established. But there are some drawbacks:

� Common side effects: Constipation, loss of appetite, gastric upset (indigestion, gas, nausea, vomiting, diarrhea), headache and dizziness, muscle and joint pain, discolored teeth

� Less common, more serious side effects: Reduced absorption of calcium, leading to increased side effects; risk of osteoporosis (loss of bone density); vitamin deficiencies due to reduced absorption of vitamins A, D, E, and K, as well as the B vitamins folic acid and niacin; decreased effectiveness of painkillers, diuretics, some diabetes drugs, some antibiotics, and some antifungal drugs

To reduce the side effects of bile acid sequestrants, the FDA suggests that you

� Start with small doses.

� Drink a lot of water to prevent constipation.

� Ask your doctor about the need for nutritional supplements and the possibility of drug interactions.

Finishing off another kind of fat: Triglyceride inhibitors

Triglyceride inhibitors are medicines that reduce your liver’s natural production of triglycerides, a fat that circulates in your blood. Lowering the level of triglycerides means you convert less dietary fat to lipoproteins. As a result, triglyceride inhibitors lower the production of LDLs, the “bad” cholesterol. No surprise there. But for some unknown reason, they also increase the levels of HDLs, the “good” cholesterol. Down with the bad, up with the good. Go figure.

The most commonly used triglyceride inhibitors are fibrates and the B vitamin niacin, which are covered in the following sections.

Fighting cholesterol with fibrates

Fibrates, also known as fibric acids, are a class of drugs that reduce blood levels of triglycerides and increase the levels of HDLs (“good” cholesterol). The fibrates include clofibrate (Atromid-S), fenofibrate (Tricor), and gemfi- brozil (Gemcor, Lopid). Because these drugs haven’t been shown to reduce the overall incidence of heart attack, they’re not considered first-line treatment.

The fibrates come in capsules to be taken twice a day — 30 minutes before breakfast and 30 minutes before dinner. What? You have to get up half an hour early to take a pill? Oh, well . . .

Because taking fibrates may raise blood sugar, these drugs are rarely prescribed for people with diabetes. Following are other possible side effects of fibrates:

� Common side effects: Allergic, itchy, skin rashes and hives; blurred vision; fatigue; gastric upset (diarrhea, gas, nausea, vomiting); headache and dizziness; muscle aches

� Less common, more serious side effects: Flu-like symptoms (chills, fever, sore throat); gallstones; kidney failure; lower blood levels of potassium; lower levels of white blood cells (the cells that protect against infection); muscle weakness or loss of muscle tissue; Raynaud’s syndrome (constriction of small blood vessels in hands and feet)

Nipping the numbers with niacin

The recommended dietary allowance (RDA) for niacin is 16 mg/day for a man, 14 mg/day for a woman. Taking much larger amounts of this familiar B vitamin appears to reduce triglycerides. For example, in various clinical trials, people taking doses of niacin up to 375 mg/day were able to cut their total cholesterol levels by up to 10 percent and their LDLs by up to 14 percent while raising their HDLs by as much as 25 percent.

In addition, niacin/nicotinic acid dilates blood vessels so that (theoretically) blood flows more easily through even clogged blood vessels. When niacin dilates blood vessels, it causes a feeling of warmth and flushing much like the “hot flashes” many women experience at menopause. To reduce this effect, doctors who prescribe niacin often opt for the sustained release or extended release form of the med. Instead of sending niacin zooming into your bloodstream as soon as — or pretty soon after — you take the pill, these babies release their niacin slowly, over several hours. In 2006 and 2007, several studies showed that combining niacin with a statin drug was an even more effective treatment.

Currently, niacin is available as a single ingredient drug either as a generic or under the brand names Niacor, Nicolar, Niaspan, and Slo-Niacin. Advicor is a sustained release combination drug containing niacin and lovastatin (Mevacor) in two doses: 500 mg niacin/20 mg lovastatin and 1,000 mg niacin/20 mg lovastatin.

Questioning a cholesterol buster

The scenario is familiar: You open your morning newspaper or turn on the evening news and read or hear that a prestigious pharmaceutical company has discovered a splendiferous new medicine that will solve one of your most pressing health problems like, oh, high cholesterol. The FDA has signed on, so you hotfoot it over to the doctor who prescibes the new med. And then what happens? Two weeks, two months, or two years down the road — “Oooops!” they say. “We think we missed something here.”

Ezetimibe (Zetia) is the first prescription drug created specifically to lower LDLs (“bad” cholesterol) by reducing your body’s absorption of the cholesterol in food. The med was introduced in 2003 as a single ingredient product (Zetia) and in 2004 as the second ingredient (along with simvastatin) in the combo pill Vytorin. When the FDA approved ezetimibe in 2003, it did so on the basis of several small trials, none of which ran longer than three months — and which hinted at trouble ahead. The people in the trial took either ezetimibe or a look-alike pill without ezetimibe, and the people in the ezetimibe group were 11 times more likely to experience serious adverse effects, most commonly liver damage. (Other possible side effects in the ezetimibe group — allergic reactions, increased risk of gallstones, and potentially serious muscle and liver damage — were described as “rare.”)

In December 2007, this situation became more troublesome when non-government experts on drug safety, including researchers at the University of Washington, discovered that Merck and Schering-Plough, the companies

that jointly market ezetimibe, had not published the data from a 2-year, 760-person clinical trial called “Enhance” that ended in April 2006 and was originally scheduled to be made public in 2007. The FDA said the agency had seen the unpublished studies and considered ezetimibe safe, but in January 2008, when the study was finally published, ezetimibe’s rep took a tumble.

The Enhance study was designed specifically to show that ezetimibe not only lowers LDLs (“bad” cholesterol), but also — like statins — reduces the buildup of plaque inside blood ves- sels that can lead to heart attack and stroke. In fact, that did not happen. Patients in the trial took either simvastatin (Zocor) alone or a com- bination of simvastatin and ezetimibe (Vytorin). Simvastatin alone lowered LDLs by 41 percent on average; simvastatin plus ezetimibe, by 58 percent. But among patients given the combi- nation pill, the plaque accumulated twice as fast as among those taking simvastatin alone. In short, taking ezetimibe appeared to increase the risk of both heart attack and stroke.

Many experts called this development “shock- ing.” Others said the data required further investigation. Congress called for an inquiry into the delay in releasing the trial results. Merck and Schering-Plough announced that the results of a longer, larger study of ezetimibe would be released in a few years. Patients and doctors fumed.

As of this writing, both Zetia and Vytorin are still on the market, but stay tuned — and if you are taking either one, be sure to check with your doctor for the latest update.

The possible side effects of single-ingredient niacin are as follows:

� Reduced effectiveness of diabetes medicines

� Reduced effectiveness of drugs used to treat gout (a form of arthritis)

� Reduced effectiveness of painkillers and anti-inflammatory drugs such as ibuprofen (Advil), naproxen (Naprosyn), and naproxen sodium (Aleve and Anaprox)

� Liver damage (high doses)

� Dizziness

Check earlier in this chapter for the side effects of statin drugs.

The word niacin is used interchangeably for two different chemical compounds, nicotinic acid and nicotinamide (also known as niacinamide). Nicotinic acid reduces levels of triglycerides. Nicotinamide does not. Also, the niacin sold as a dietary supplement (vitamin) isn’t a substitute for prescription niacin, a product whose use must be monitored by your doctor.

Comparing the Benefits of Cholesterol-Buster Drugs

Assuming that you worked your way through all the paragraphs before this, you’re now definitely an expert on the virtues of the various drugs your doctor may prescribe to lower your cholesterol. What? You didn’t read every single word? Twice? Not to worry. Table 12-2 pretty much sums it all up as of Winter 2008.

The doses listed in Table 12-2 are the highest prescribed in one day. They are not the doses prescribed for every patient. In fact, your doctor may achieve satisfactory results — lower LDLs — with lower doses. Do not change your dose of any of these medicines without your doctor’s approval!

Picking the Perfect Pill Candidate

Should you be using a cholesterol-lowering medicine? Maybe. One way to decide is to review the recommendations of the experts at the National Heart, Lung, and Blood Institute’s Web site: www.nhlbi.nih.gov. The recommendations are contained in two reports:

� The Third Report of the Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel III)

� ATP III Update 2004: Implications of Recent Clinical Trials for the ATP III Guidelines

To save time, ink, and the lives of all the trees that would otherwise be cut down to make the paper for the extra pages required to print that entire title over and over again, I’ve made an important decision. From now on, I refer to these reports by their nicknames: ATP III and ATP III Update. If you’re absolutely committed to reading both reports in their mind-numbing entirety, feel free to visit www.nhlbi.nih.gov/guidelines/cholesterol/index.htm.

Meanwhile, I dance through the highlights:

� In the context of ATP III and ATP III Update, a major risk factor is diabetes, high blood pressure, high levels of LDLs, high levels of triglycerides, smoking, being older than 45 (men) or 55 (women), or having a family history of early heart disease (before 55 for your dad, before 55 for your mom).

� To estimate your risk of suffering a heart attack in the next ten years, click the interactive National Cholesterol Education Project (NCEP) Risk Assessment Tool for Estimating Your 10-Year Risk of Having a Heart Attack at http://hp2010.nhlbihin.net/atpiii/calculator.asp.

No computer handy? Zip over to the library computer, or check with your doctor.

Categorizing risk

ATP III divided Americans into four large categories based on their risk of heart disease. The categories are

� High risk: Known coronary artery disease and/or blocked arteries in the legs or brain, plus multiple major risk factors

� Intermediate risk: No known vascular disease, at least two major risk factors, and 10 to 20 percent risk of heart attack in the next ten years

� Moderate risk: No known vascular disease, at least two major risk factors

� Low risk: One or no major risk factors, less than 10 percent risk of heart attack in the next ten years

The ATP III Update revised the risk categories as follows

� Very high risk: Previous heart attack or stroke, plus several major risk factors

� High risk: Known coronary artery disease and/or blocked arteries in the legs or brain, plus multiple major risk factors

� Moderately high risk: No known vascular disease, at least two major risk factors

� Moderate risk: No known vascular disease, at least two major risk factors

� Low risk: One or no major risk factors, less than 10 percent risk of heart attack in the next ten years

As a result of this update, several million more Americans were now classified as being at high risk or very high risk, necessitating — you guessed it — more meds.

Recommending treatment

The treatment recommendations in both ATP III and ATP III Update are both based on the proposition that lowering a person’s level of LDLs lowers her risk of heart attack. The difference lies in the decision about who needs to be treated and how low she needs to go.

ATP III’s treatment recommendations were simple:

� The first line of defense in ATP III is diet. The report recommends that a whopping 65 million Americans change what they eat in order to lower their cholesterol.

� If changing the diet doesn’t do the trick, the NHLBI recommends that an almost-equally-whopping 35 million Americans with a more than 20-percent risk of heart attack in the next ten years and/or an LDL level higher than 130 mg/dL begin drug treatment to push their LDLs down to 100 mg/dL.

The treatment recommendations in the ATP III Update are dramatically different:

� For people in the very high risk and high risk categories, the recommended level of LDLs was lowered to 70 mg/dL, a level virtually impossible to reach without drugs.

� If a very high-risk or high-risk person has high levels of triglycerides, a fibrate or nicotinic acid should be given along with a cholesterol- lowering med.

� The best option for moderately high-risk people is to aim for LDL levels less than 100 mg/dL. Any moderately high-risk person with LDL levels of more than 130 mg/dL plus major risk factors is a candidate for cholesterol- lowering drugs.

� Low-risk people don’t have to take cholesterol-lowering drugs.

Seems like practically everyone you know is a candidate for cholesterol-buster meds. Not surprisingly, that conclusion hasn’t been universally applauded.

Many critics note (correctly) that the ATP III Update pretty much ignores the benefits of lifestyle changes such as diet and exercise, while passing over studies showing virtually no benefits in giving cholesterol-lowering meds to older people. Others are distressed by the makeup of the ATP III Update panel: Eight of the nine panel members had financial ties to companies producing cholesterol-lowering drugs. Ooops.

As the debate simmers, will the ATP III Update recommendations become the norm? Maybe. Should you check with your own doctor before diving into drugs? You bet. Case closed.

Read More

Vitamins, Minerals, and Other Good Stuff: Naming nutrients that fight cholesterol, Discovering the power of niacin, Chewing on some fiber and Planting the anti-cholesterol seed.

Vitamins, Minerals, and Other Good Stuff

In This Chapter

� Naming nutrients that fight cholesterol

� Discovering the power of niacin

� Chewing on some fiber

� Planting the anti-cholesterol seed

One day, vitamins, minerals, and phytochemicals (phyto = plants) are the cat’s meow. The next day, they’re thrown out with the cat’s litter. Although taking vitamin pills and other nutritional supplements is sometimes touted as one way to lower cholesterol, most studies come up a bit short of proclaiming it a certainty. Or worse: At least one study shows that taking extra vitamins may reduce the effectiveness of cholesterol-lowering medications.

As a result, the best advice on supplements may be one that’s tried and true (and a bit boring): A balanced diet beats supplements hands down. In this case, I’m talking about a balanced, low-cholesterol, controlled-fat diet. A few exceptions exist to the advice I just laid on you, and I promise to discuss those exceptions in this chapter, along with all the info you need concerning cholesterol and how it relates to vitamins, minerals, fiber, and other dietary supplements.

For the lowdown on cholesterol-lowering prescription meds, check out Chapter 12; for cholesterol-lowering diets, your best bets are Chapters 4 and 5.

Identifying Supplements

Every year, Americans snap up more than $3 billion worth of nutritional supplements. Some people use them for “nutritional insurance;” others see supplements as a quick and easy way to get vitamins, minerals, and other good stuff without the pesky fat and sugars found in food.

But you’re reading a book about cholesterol, so for you, the most interesting statement about supplements may be that some appear to help lower total cholesterol and low-density lipoproteins (LDLs) while raising high-density lipoproteins (HDLs), the cholesterol particles you can read more about in Chapter 2.

The U.S. government considers dietary supplements to be food products, not drugs. As a result, supplements aren’t regulated as strictly as drugs, and very few serious studies exist to show how these pills affect cholesterol. Every rule, however, has an exception. Which is the point of this chapter, so read on.

Popping a Vitamin and Mineral Pill May Help Lower Cholesterol

Some nutrients play an important role in keeping your heart healthy. For example, calcium enables muscle cells, including heart muscle cells, to send messages back and forth, and selenium protects against Keshan disease, a disorder of the heart muscle whose symptoms include rapid heartbeat, enlarged heart, and (in severe cases) heart failure.

But when it comes to lowering cholesterol, most nutrients are no-shows. The one stellar exception is niacin. The maybes are vitamin E, vitamin C, and calcium.

How niacin helps control cholesterol

Niacin is a B vitamin considered essential for proper growth and develop- ment. It’s intimately involved in the work of enzymes, naturally occurring compounds in your body that power various processes such as digestion.

In fact, niacin is a component of one enzyme that enables oxygen to flow into your body tissues. Like thiamin (vitamin B1), niacin helps you maintain a healthy appetite. It also participates in the digestion of sugars and fat. You get niacin directly from these foods:

� Dairy products: Your body converts the amino acid tryptophan found in milk and dairy foods into niacin.

� Grains: Grains are a source of niacin, but your body can’t absorb them efficiently unless they’ve been treated with lime (the mineral, not the fruit — see the nearby sidebar “Limelicious”).

� Meat, fish, and poultry: No need to explain these three, right?

The niacin you get from food helps your body function in all of these ways, and it also protects you against the niacin-deficiency disease pellagra. The symptoms of pellagra include diarrhea, skin lesions, confusion, and dementia. But the amount of niacin found in food is too small to affect your cholesterol. For that, you need industrial-strength niacin.

Numbering normal niacin needs

In the United States, the recommended dietary allowance of each nutrient is usually abbreviated as RDA, a term comparable to the Canadian RNI (recommended nutrient intake).

The RDA for niacin is described in terms of niacin equivalents (NE), as in milligrams of niacin equivalents (mg/NE). For example, 60 mg of tryptophan (an amino acid in milk) = 1 mg of niacin = 1 niacin equivalent (mg/NE).

The basic adult requirement for niacin is 14 mg/NE per day for women and 16 mg/NE per day for men. The amount of niacin required to lower cholesterol levels is dramatically higher.

Measuring medically-effective levels of niacin

If you take an immediate-release form of niacin, a product that sends the vitamin right into your bloodstream, the starting dose is 100 mg/NE three times a day. The starting dose for an extended-release form of niacin, a product that releases the niacin gradually into your bloodstream, is one 375-mg/NE pill once a day.

So much for the techy details. Now, on to the practical part.

Balancing the benefits and risks of medical-strength niacin

As a medication, large doses of niacin

� Lower your triglycerides (fats in your blood; see Chapter 2)

� Lower your total cholesterol up to 10 percent

� Lower your LDLs by as much as 14 percent

� Raise your HDLs by as much as 25 percent

Limelicious

Treating grain with lime is a common practice in Central American and South American countries. Lime enables the body to absorb the niacin efficiently. In these countries, lime is added to cornmeal used to make tortillas.

In the United States, breads and cereals are routinely fortified with niacin, which makes the use of lime unnecessary.

So far, everything sounds pretty good, but like most medication, a cholesterol- lowering dose of niacin has potential side effects. Like what?

� Like a niacin flush, a feeling of sudden warmth similar to the hot flashes some women experience at menopause, which is kind of weird if you’re not yet in menopause — or if you’re male

� Like making your diabetes or arthritis medication less effective

� Like skin rashes, hives, itching, muscle pain, peptic ulcers, upset stomach, nausea, diarrhea, liver damage, vision problems, dizziness, and fainting Call 911 or go immediately to the closest emergency room if you experience any of these symptoms while taking niacin supplements.

Worse yet (can it really get worse?), if you develop any of these symptoms and decide to stop taking niacin cold turkey, your total cholesterol and your LDLs will rebound, zooming skyward, almost certainly higher than they were before you started taking niacin.

One way to avoid this state of affairs is to taper off niacin, taking a little bit less every day.

If a pill — including a vitamin pill — is powerful enough to alter your cholesterol profile, it’s powerful enough to be troublesome — an example of how something natural may be helpful but not necessarily harmless.

For more info on niacin and other cholesterol-lowering medications, turn to Chapter 12.

Evaluating vitamin E and vitamin C

Vitamin E is a fat-soluble nutrient (a vitamin that dissolves in fat and can be stored in your fatty tissue). Vitamin C is water-soluble (a vitamin that dis- solves in water and is eliminated when you urinate). But the two nutrients have one interesting trait in common: Both are antioxidants.

Antioxidants are substances that prevent fragments of molecules from hook- ing up to form potentially damaging compounds inside your body.

For example, many cured meats contain added vitamin C and vitamin E to prevent fragments of preservatives called nitrates and nitrites from hooking up to form carcinogens called nitrosamines.

Linking antioxidants and cholesterol

Low-density lipoproteins (LDLs) are fat-and-protein particles sometimes called “bad” cholesterol because they ferry cholesterol into arteries. Combining with oxygen makes LDLs more damaging.

So it seems reasonable to assume that anything that prevents LDLs and oxygen from mating should lower your risk of clogged arteries.

One such “anything” may be antioxidant vitamins. In fact, during the 1990s, several major scientific studies at thoroughly reputable scientific institutions suggested that antioxidant vitamins E and C could protect your heart muscle and blood vessels from cholesterol damage.

This led many respected scientists (and some nutritional theorists) to say that taking a lot of E and C would be good medicine. But they may have been off on the wrong path.

More recent studies suggest contrary conclusions: Taking antioxidant vitamins may reduce the effectiveness of cholesterol-lowering statin drugs, and antioxidant vitamins may actually convince your liver to churn out more cholesterol.

Subverting the statins

In August 2001, Atherosclerosis, Thrombosis, and Vascular Biology, a journal of the American Heart Association, published a report from a one-year study at the University of Washington School of Medicine.

The study included 153 volunteers between the ages of 33 and 74 who had arteries narrowed by cholesterol plaque and low levels of HDLs, the “good” cholesterol. Each volunteer was randomly assigned to one of the following “treatment” regimens:

 Regimen #1: The cholesterol-lowering drug Simvastatin (Zocor), plus niacin, and antioxidant vitamins E and C (for a rundown on Simvastatin and other “statins” see Chapter 12)

� Regimen #2: Simvastatin and niacin

� Regimen #3: Antioxidant vitamins alone

� Regimen #4: A placebo (pill with inactive ingredients; basically a sugar pill)

Ordinarily, both Simvastatin and niacin lower total cholesterol and LDLs while boosting HDLs, but volunteers who took Simvastatin, niacin, and antioxidants experienced a smaller increase in HDLs than volunteers who took the drugs alone, and their levels of HDL (2) — a kind of “super good” cholesterol — didn’t budge a bit. Boy, did that surprise the researchers!

As a result, the editorial accompanying the report concluded that doctors should tell their patients that taking antioxidants with a statin drug, such as Simvastatin, or with niacin may not be a good idea.

But the editorial also noted that the study was so small that it couldn’t be considered conclusive, especially since vitamin E — a natural anticoagulant that reduces the risk of blood clots — has been shown to lower the risk of heart disease.

Ticking off tocotrienols

Tocotrienols are phytochemicals similar to vita- min E. One measly study shows that taking tocotrienols lowers LDLs, so some companies are packing tocotrienols in pills and selling them as cholesterol-lowering supplements.

But if you take vitamin E while taking tocotrienols, the former cancels out the effects of the latter. Too complicated for me!

Then, believe it or not, results from another study, this one from Oxford University (England), showed no ill effects from combining antioxidants with a statin drug, leading the Brits to suggest that the problem may lie with the niacin.

Making the body make more cholesterol

In April 2004, a team of researchers at New York University School of Medicine’s Lipid Treatment and Research Center reported that when mice were fed a diet rich in the antioxidant vitamins E, C, and beta-carotene, their livers churned more than normal amounts of VLDLs (very low-density lipoproteins).

VLDLs are one form of LDLs, the fat-and-protein particles that carry cholesterol into arteries. (For more on the various forms of lipoproteins, see Chapter 2.)

Would this also happen in human beings? The researchers couldn’t say for sure; after all, mice aren’t people.

However, the study — plus a raft of others casting doubt on the anti- cholesterol powers of antioxidants — may have been what led the American Heart Association to issue the following statement in 2007:

“The American Heart Association doesn’t recommend using antioxidant vitamin supplements until more complete data are available. We continue to recommend that people eat a variety of nutrient-rich foods daily from all the basic food groups.”

Can calcium supplements counter cholesterol?

Remember when your mother told you to drink your milk because — all together now — “Calcium makes strong bones and teeth.” Would mom say the same thing about calcium’s ability to lower the level of cholesterol circulating in your older body? Maybe.

In May 2003, a team of researchers from the Department of Medicine at the University of Auckland (New Zealand) reported that when 223 postmenopausal women who weren’t being treated for high cholesterol or osteoporosis were given either calcium supplements (1 g/day) or a placebo (a look-alike pill with no calcium) for 12 months, HDL levels rose about 7 percent among those taking the calcium, while LDL and total cholesterol levels went down slightly.

Conclusion? For older women, calcium supplements may protect arteries, as well as bones. Good job, mate.

Fighting Cholesterol with Dietary Fiber

As you can read in Chapter 5, there are two kinds of dietary fiber — insoluble dietary fiber (which doesn’t dissolve in your intestinal tract) and soluble dietary fiber (which does dissolve in your gut).

There’s absolutely no doubt that eating foods like beans, fruits, veggies, and grains, which are all high in soluble dietary fiber, lowers your cholesterol. You can read all about oatmeal and beans, the quintessential soluble-dietary- fiber factories, in Chapter 6.

But suppose you totally loathe high-fiber foods. Suppose just looking at fruits, veggies, grains, and beans makes you go, “Ugh!” Far be it from me to say, “Boy! You’re missing some good stuff.” No, my job here is to answer the question dancing across your lips: “Can I get my fiber from supplements?” Well . . . maybe.

Soluble dietary fiber lowers your cholesterol levels by mopping up cholesterol in your digestive tract before it gets into your bloodstream. To do this job effectively, the fiber must absorb water and form a gel.

To date, more than 50 separate scientific studies (notice the subtle, albeit compelling, alliteration) attest to the ability of some soluble-fiber supplements to lower total cholesterol and LDLs. The soluble dietary fibers most often studied in these tests are

� Guar gum: A sticky, soluble dietary fiber from a plant commonly cultivated in India as cattle feed. Guar gum is also known as guar flour or bentonite.

� Pectin: A soluble fiber found most prominently in apples.

� Psyllium: A sticky soluble fiber also known as plantago seed or plantain seed.

But not all supplements containing these fibers are equally effective. For a soluble-fiber supplement to lower your cholesterol, it must form a strong gel that can attract and hold cholesterol in your gut. Unfortunately, some methods of processing fiber to make supplements break up the strands of carbohydrates that form the gel, thus weakening the whole darned thing.

To be certain that a dietary-fiber supplement will actually lower cholesterol, the manufacturer has to test it, a time-consuming and expensive process. As a result, very few fiber supplements can actually prove they will lower your cholesterol. Sorry about that.

Psyllium alert! Psyllium alert! Some people are allergic to psyllium. If they eat the stuff, they may end up with hives or a rash, respiratory problems, or — worst-case scenario — the potentially lethal, whole-body reaction called anaphylaxis. In other words, something natural may be helpful but not necessarily harmless. If you consume some psyllium and start feeling itchy or have trouble breathing, get to the nearest emergency room or call an ambulance.

Phabulous Phytochemicals

Perhaps the most fascinating nutritional discovery of the past several years has been the identification of phytochemicals, naturally occurring compounds in plants. Some of these compounds actually mimic powerful medicines such as the female sex hormone estrogen and the cholesterol-lowering statin drugs. Who wouldn’t be impressed with these natural wonders?

Sticking with sterols

Plants are great little pretenders. They often manufacture compounds that resemble chemicals found in animal (human) bodies but don’t seem to carry the problems associated with animal (human) chemistry.

One good example is phytosterols, substances that resemble cholesterol so closely that your digestive tract can’t tell what’s a phytosterol and what’s cholesterol.

If you eat phytosterols along with a meal that includes cholesterol, your body is likely to absorb phytosterols (which won’t clog your arteries) in place of cholesterol (which may).

This principle has inspired the creation of special cholesterol-lowering margarines that promise to change your cholesterol profile for the better, although the exact decrease in total cholesterol and LDLs and the increase in HDLs will vary with the dose and the body. For more on the sterol margarines, see Chapter 6.

As with dietary fiber supplements, the question here is whether you can cram enough of the good stuff into a pill to let you take your sterols as a supplement rather than a food. This time, the answer is why bother? The sterol studies say you must wolf down at least 3,000 milligrams (mg) of sterols per day to produce a noticeable change in your cholesterol levels. Each table- spoon of sterol margarine provides 1,700 mg, so two tablespoons per day more than does the trick.

By comparison, the University of California Berkeley Wellness Letter says that the doses of sterols in supplement pills are “too small to have any effect.” How small? Usually in the under-400-mg-per-pill range, which means you’d need about eight pills a day to make a difference. I say, pass up the pills, and “butter” (note the qualifying quote marks) your bread.

The sterols in sterol margarine or cholesterol-lowering supplements aren’t the same as the steroids sometimes used illegally by athletes to bulk up their muscles. Do I need to add that steroids, which can really mess up your body systems, are a definite no-no? Make that, NO-NO. And go ahead and add an exclamation point, as in never, ever use these drugs!

Getting the goods on garlic supplements

As a food, garlic is yummy. As a cholesterol buster, it’s so-so. In the mid-1970s, a number of studies suggested that phytochemicals in garlic, particularly the smelly mustard compounds such as allicin, were useful in lowering cholesterol. Later research is mixed.

Some studies say, yes, garlic and garlic supplements can lower cholesterol. Others say not in this lifetime. In 2007, Christopher Gardner, assistant professor of medicine at Stanford University, ran a trial with 192 adults — in this case, people older than 50 — whose average LDL level was 140. Six days a week for six months, the volunteers were given the equivalent of one clove of garlic (either as a pill or as plain raw garlic mixed into food) or a dummy pill. Monthly blood tests failed to show any change in cholesterol levels, but more than half the people who got garlic reported bad breath and body odor.

Conclusion: Pass this supplement by. Otherwise, people may pass you by.

Waiting for the Next Study

This section may be a good opportunity to remind you that it takes a while to shake down all the data from new medical studies and that this situation sometimes leaves doctors and patients confused.

At one recent medical convention, speakers presented the findings from four large treatment trials whose aim was to determine if taking vitamin E may help prevent heart attack. Three of the trials showed that vitamin E had no beneficial effect on the heart, and one showed that vitamin E caused more heart attacks than the placebo.

At the beginning of the presentations, the doctors in the audience were asked, “How many of you are taking vitamin E for your heart?” and about half of them raised their hands.

After the presentation of the trials, the doctors were asked, “How many of you will be taking vitamin E in the future?” and no one raised his or her hand.

Who’s right? I hate to say this, but who knows? The only conclusive answers about vitamins, minerals, phytochemicals, and cholesterol will come — arrrgh! — with time.

Read More

The Grape, the Grains, and Your Cholesterol: Drinking (moderately) to your health, Watching your alcohol intake, Knowing the risks of ignoring the moderately part and Getting the scoop on the nutrients in alcohol.

The Grape, the Grains, and Your Cholesterol

In This Chapter

� Drinking (moderately) to your health

� Watching your alcohol intake

� Knowing the risks of ignoring the moderately part

� Getting the scoop on the nutrients in alcohol

Alcohol beverages are among mankind’s oldest home remedies and simple pleasures. The ancient Greeks and Romans called wine a gift from the gods — now that’s holding it in pretty high regard. As for distilled spirits, the Gaels (early inhabitants of Ireland) called them uisgebeatha (whis-key-ba). The French came up with eau de vie (o-duh-vee). And the Scandinavians dubbed the hard stuff aquavit (ah-kwa-veet). Take your pick — they all mean “water of life.”

The funny thing is that this translation may turn out to be a scientifically accurate description. Drinking moderate amounts of alcohol appears to benefit your heart. (No, that doesn’t mean you should start drinking if you’ve been abstaining from drinking up to now.)

Yes, excessive drinking is hazardous to your health, and you can read about that later on in this chapter, but first, the good stuff, including alcohol’s ability to lower your cholesterol.

Wait! One more thing. Throughout this chapter — and throughout this book — beer, wine, and spirits are called alcohol beverages, not alcoholic beverages. After all, who ever heard of a beverage that can drink enough to become an alcoholic?

Toasting to Your Heart

The Dietary Guidelines for Americans 2005 from the U.S. Department of Agriculture and Department of Health and Human Services is a primer for healthy eating (and drinking). So you may be interested to read that the guidelines state flat out that compared to nondrinkers, adults who consume one to two alcohol beverages a day appear to have a lower risk of coronary heart disease.

Clearly, the Guidelines’ authors, sober scientific ladies and gentlemen every one, have been doing their reading. Which is to say, they’ve been looking at a series of recent studies showing that moderate use of alcohol beverages has the following effects:

� Lowers total cholesterol

� Raises levels of “good” cholesterol (check out these high-density lipoproteins, also known as HDLs, in Chapters 2 and 3)

� Lowers blood pressure

� Relaxes muscles (including the heart muscle)

Okay, you’re right. Maybe that last bullet point doesn’t affect your cholesterol, but it does make you feel good. Does all this sound good enough for you to take a look at the data that convinced the experts? If so, keep reading.

Studying the studies

The evidence that moderate drinking benefits the heart comes from really reliable studies from real, reliable sources, such as the American Cancer Society (ACS), the American Heart Association (AHA), and the long-running, 70,000-women Nurses’ Health Study (NHS) from the Harvard Medical School, Harvard School of Public Health, and Brigham and Women’s Hospital in Boston. Hey, it don’t get more reliable than that, right?

Here are the studies of proof:

� Really Reliable Study #1: The ACS’s Cancer Prevention Study I (CPS-I) fol- lowed more than 1 million Americans in 25 states for 12 years. Analyzing the lifestyles of 276,802 middle-aged men and the circumstances of those who died during the study period, the researchers concluded that men who drink moderately lower their risk of heart attack — 21 percent lower for men who have one drink a day than for men who never drink. In addition, men who have one or two drinks a day are 22 percent less likely to die of a stroke.

� Really Reliable Study #2: An analysis of the data for nearly 600,000 women in CPS-I showed that, like men, women who drink occasionally or have one drink a day are less likely to die of heart attack than women who don’t drink at all.

� Really Reliable Study #3: In 2002, researchers at the NHS issued a new report on 70,891 women who were 25 to 42 years old when the study began in 1989. This time the subject was alcohol. The conclusion? Women who have one-quarter to one-half drink a day — in real life, this equals two or three drinks a week — are 15 percent less likely to develop high blood pressure than women who never drink. At the other end of the spectrum, women who have more than ten drinks a week are 30 per- cent more likely to have high blood pressure. The results were the same regardless of the type of drink (beer, wine, or spirits) the women preferred. Nice.

Subscribe to the NHS newsletter, which details the current progress of both the original Nurses’ Health Study and the Nurses’ Health Study II. Visit www.channing.harvard.edu/nhs/newsletters/index. shtml.

What happens as alcohol moves through your body?

How is it that alcohol beverages may benefit your heart, your blood vessels, and your cholesterol profile? First, a bit of physiology. Unlike other foods, which must be digested before your cells can absorb them, alcohol can flow directly through body membranes into your bloodstream.

For example, when you eat a burger, none of its protein, fat, carbs, vitamins, or minerals get into your bloodstream until the burger has made its way through your stomach and your small intestines.

The latest edition of Nutrition For Dummies (Wiley), which I also wrote, has an entire chapter on how alcohol affects your body. But for an outline of the path that the grape juice, oops, alcohol takes, check out these steps:

1. You take a sip of a really good merlot (or my personal favorite, Chianti).

2. Small amounts of alcohol immediately pass through the membranes of your mouth and throat into your bloodstream.

This process happens so fast that the alcohol reaches your brain within seconds of your sip.

3. Some of the alcohol goes directly from your stomach to your bloodstream.

4. Most of the alcohol goes from your bloodstream to all the organs (such as your heart) in your body.

5. Alcohol relaxes the heart muscles, reducing the force with which the muscle contracts (your heartbeat).

6. Your heart pumps out slightly less blood for a few minutes.

7. When your heartbeat slows and your heart pumps out less blood, a couple of things occur:

• Blood vessels all over your body relax, and your blood pressure goes down.

• Blood platelets — the particles that make it possible for blood to clot — become less sticky and less likely to clump together. For a while (oh, maybe an hour or so), your risk of blood clot-related heart attack and stroke goes down.

8. Your heart muscle’s contractions soon return to normal, but as the alcohol circulates through your body, your blood vessels may remain relaxed, and your blood pressure may remain low for as long as half an hour.

Although the immediate result of moderate drinking is beneficial, heavy drinking or alcohol abuse can raise your blood pressure over the long term.

Focusing on cholesterol

Lipoproteins, the fat-and-protein particles on which cholesterol travels, come in two varieties:

� HDLs (high-density lipoproteins) are labeled good because they carry cholesterol out of the body.

� LDLs (low-density lipoproteins) are called bad because they take cholesterol into your arteries.

But as Chapter 2 explains, when you’re talking lipoproteins, size is as important as type because large LDLs are less likely than small LDLs to make their way into arteries.

The Cardiovascular Health Study (CHS), funded by the National Heart, Lung, and Blood Institute (NHLBI) was designed to evaluate risk factors for heart disease in men and women 65 and older. Data from the 1,850-person study, which ran from 1989 to 1999, has served as a base for more than 400 research papers and 120 follow-up studies.

In 2007, a team of researchers from Beth Israel Deaconess Medical Center (Boston), the University of Pittsburgh, the University of Vermont (Burlington) and the University of Washington (Seattle) combed through the CHS’s data in search of medical gold. What they found was that men and women who consumed 7 to 13 drinks a week had the highest number of small LDLs, which have a higher chance of getting into the arteries, thus increasing their risk of blockage. Score another round for moderation — one to two drinks a day.

Identifying Alcohol’s Heart-Healthy Compound

If you’ve read the previous pages of this chapter, you’ve gathered that moderate drinking has a few benefits. But what exactly is in the alcohol beverages that does the trick? I’m glad you asked.

Unfortunately, the studies that show alcohol’s benefits for your heart and blood vessels don’t necessarily agree on exactly which kind of alcohol beverage or which constituent in the beverage makes moderate amounts of alcohol beneficial. Is it the alcohol itself? Or something else?

Surveying the studies

On the one hand, lots of studies show similar benefits with all kinds of alcohol beverages — beer, wine, and spirits — suggesting that the active ingredient may simply be the alcohol.

On the other hand, one or two studies have shown special benefits for beer. The best you can say about this development is that it’s just one or two studies; before accepting this as a medical gospel, you’d have to see — yes — more studies.

Grooving on grapes

Grape skins and pulp are rich in resveratrol, and grapes belong on a heart-healthy diet. Not only are they low in calories, they’re high in nutrients and yummy as all get out. A single serving of 20 green Thompson seedless or deep-red Tokay or Emperor grapes has 70 to 80 calories, 12 to 16 percent of the recommended daily allowance of vitamin C, and up to 84 percent of the potassium in 1⁄2 cup of orange juice. And there’s a teensy little bit of dietary fiber in the grape’s skin, plus astringent tannins that make your mouth pucker.

Maybe that’s why Mae West, your great-great- grandpa’s sex symbol, whose delightfully raunchy wit is available today on DVDs from the very modern Amazon.com, used to ask her beaus to “peel me a grape.” If you want to peel the grapes you toss into your fruit salad, choose American varieties such as the Catawba, Concord, Delaware, Niagara, or Scuppernong. These grapes are called “slipskins” because (surprise) the skin comes off easily. Peeling a European variety, such as an Emperor, Tokay, Malaga, Muscat, or Thompson, is more of a challenge. Here’s a little Euro-grape-peeling lesson:

1. Drop the grape into boiling water for a few seconds.

2. Then fish it out with a slotted spoon (to spare your fingers).

3. Finally, plunge the little darling into cold water.

The hot water makes the water under the skin expand so the skin swells; the cold water makes it burst and peel back.

Or you can just eat your grapes with the skin on.

Note: Ounce for ounce, you get more resveratrol from grape juice than from plain grapes. The darker the juice, the higher the resveratrol. Drink up! The following minitable shows you the nutrients in grapes and grape juice, depending on the kind of grapes you ingest.

On the third hand — there’re always more than two hands in this kind of discussion — the first hint of alcohol’s heart benefits showed up in France, where folks eat lots and lots of high-fat food — pâté! cheese! butter! — but generally have a lower rate of heart disease than people in the United States. Researchers eventually linked this situation, sometimes called “The French Paradox,” to the facts that (a) the French serve their fatty foods in very small portions, and (b) the French also drink lots and lots of wine.

Nothing in science is ever simple, is it?

Since researchers have turned their attention to the heart-healthy French, several studies have shown a correlation between low heart disease, favor- able cholesterol profiles, and red wine consumption. This research leads to the interesting possibility that the important ingredient in alcohol is actually something in the skin, pulp, and seeds of grapes — the parts of the fruit more widely used in making red wines. Ladies and gentlemen, meet resveratrol.

Zeroing in on resveratrol

Resveratrol is a flavonoid, one of a group of plant chemicals credited with lowering cholesterol and reducing inflammation of body tissues, such as the lining of blood vessels, thus reducing your risk of heart attack.

The juice from purple grapes has more resveratrol than the juice from red grapes, which has more resveratrol than the juice from white grapes. (Get the red wine connection?) To be even more specific, in 1998, a team of food scientists from the USDA Agricultural Research Service identified a native American grape, the muscadine, as an unusually potent source of resveratrol. About half of all muscadines grown in the United States are used to make grape juice. With that in mind, nondrinkers can get their resveratrol from grapes and grape juice. Don’t you love it when science serves up something for everybody?

Drinking in Moderation

So far in this chapter, we’ve been talking about the benefits of moderate drinking. Here’s what “moderate drinking” means, from the Dietary Guidelines for Americans:

� One drink a day for a woman

� Two drinks a day for a man

Damaging the liver

Alcohol has to be metabolized in the liver by ADH, which is found in the mitochondria (the cellular powerhouses that convert nutrients into energy-yielding molecules that fuel the cells) of the liver cells. If the amount of alcohol presented to the mitochondria exceeds the amount of alcohol the enzyme can detoxify, the alcohol poisons the mitochondria and causes the liver cell to die.

The first change in the liver is seen as fat depositing in the liver cells. If excessive alcohol ingestion is continued, alcoholic hepatitis (an inflammation within the liver cells) occurs.

If excessive ingestion of alcohol is stopped at either of these first two stages, the liver cells may return to normal.

The liver is one of the few regenerative organs in the body. If you surgically remove half of the liver, the body will regrow the half that’s removed. If, however, excessive alcohol ingestion continues, cirrhosis, the final stage of liver damage, occurs. Cirrhosis is a scarring of the liver cells that’s an irreversible stage of liver disease and frequently leads to death.

Why does moderate mean different things for men and women? It’s an enzyme thing. To metabolize (to get rid of, to use up) the alcohol you drink, your body calls on enzymes called alcohol dehydrogenases (ADH). You produce one form of ADH — gastric alcohol dehydrogenase (GADH) — in your stomach (where alcohol metabolism begins) and another form of ADH in your liver, the primary alcohol-metabolizing plant.

The average woman makes less GADH than the average man. As a result, more unmetabolized alcohol flows from her stomach into her bloodstream on its way to her liver. With more unmetabolized alcohol in her blood, the average woman is likely to become tipsy on smaller amounts of alcohol than is necessary to produce the same effect in the average man.

Most people (men as well as women) need a full hour to produce enough ADH to metabolize the amount of alcohol — 1⁄2 ounce — in one drink. But that’s an average: Some people still have unmetabolized alcohol circulating in their blood for as long as two to three hours after they take a drink.

Which brings me to the next question: What’s one drink? According to the American Heart Association, one drink equals

� 12 ounces of regular beer

� 5 ounces of wine

� 1.5 ounces of 80 proof distilled spirits

� 1 ounce of 100 proof distilled spirits

What makes these different amounts of beer, wine, and spirits equivalent? Each serves up approximately 15 grams of ethyl alcohol, the only alcohol used in alcohol beverages.

Checking Out the Risks, Too

Alcohol is a serious product. Having read this far, you know it has benefits. But you can assume that it also has risks. You’re right.

The following sections focus on the risks of alcohol consumption.

Alcohol and cancer

The same studies that applaud the effects of moderate drinking on heart health are less reassuring about the relationship between alcohol and cancer:

� The American Cancer Society’s Cancer Prevention Study I shows that people who take more than two drinks a day have a higher incidence of cancer of the mouth and throat (esophagus).

� Researchers at the University of Oklahoma say that men who drink five or more beers a day double their risk of rectal cancer.

� American Cancer Society statistics show a higher risk of breast cancer among women who have more than three drinks a week.

The reassuring note? With the exception of breast cancer, the damage appears to be linked to amounts of alcohol that exceed the moderate levels set by the Dietary Guidelines for Americans. For info on the moderate levels, see the “Studying the studies” section earlier in this chapter.

Alcohol and birth defects

Fetal alcohol syndrome (FAS) is a collection of birth defects including (but not limited to) low birth weight, heart defects, retardation, and facial deformities.

FAS has been documented only in babies born to women who experts describe as “chronic alcohol abusers who drink heavily during pregnancy.” No evidence ties the syndrome to one or two drinks during pregnancy, or even one or two drinks a week during pregnancy.

About 7 percent of the babies born in the United States each year have a birth defect. Often the parents of these children feel guilty even though their behavior had absolutely nothing to do with the birth defect. To make the case even stronger, the U.S. federal government requires that a warning about birth defects appear on all bottles of alcohol beverages.

To date, no solid scientific medical evidence says, “Avoid all alcohol while pregnant.” But human beings are complicated forms of life, and the possibility of lifelong guilt if you have a drink while pregnant and then deliver a child with birth defects isn’t worth the moment’s pleasure.

Alcohol and the morning after

The stories from the morning after a night of too much alcohol aren’t fiction. They’re a miserable physical fact.

If you ever have too much to drink one evening, the next morning you may experience many of the following symptoms:

� You’re thirsty because alcohol, a diuretic, has caused you to lose a lot of water through excessive urination.

� Your stomach hurts because alcohol irritates your stomach lining.

� You’re queasy because having your stomach irritated stimulates the release of extra stomach acid and histamine, the same immune system chemical that makes the skin around a mosquito bite red and itchy. (Who wouldn’t be queasy when her stomach looks like one big bug bite?)

� Your muscles ache because processing alcohol through your liver requires an enzyme normally used to convert lactic acid, a byproduct of muscle activity, to compounds you can use for energy. The extra lactic acid piles up painfully in your muscles.

� You have a headache. Alcohol dilates (relaxes) blood vessels, including some in your scalp. The dilated blood vessels swell, making your head hurt.

And when you’re talking headache, don’t forget the Red Wine Problem. When grapes ferment, their protein molecules split into fragments. One fragment, called tyramine, slows your body’s metabolism of alcohol, so alcohol keeps circulating through your bloodstream, causing a headache and other unpleasant sensations. Red wine has more tyramine than other kinds of alcohol.

A word to the wise

When experts talk about alcohol abuse, they don’t mean warming the vodka or chilling the brandy. The foodies among us may wince, but these gourmet gaffes aren’t the point. They mean allowing alcohol to interfere with your ability to enjoy a normal, productive life. If you or someone you know is drinking too much, too often, don’t miss this easy opportunity to find help.

1. Get up right now and walk over to your computer.

2. Turn it on.

3. Connect to the Internet.

What? You have broadband and it’s always

on? Well, skip this step and go to Step 4.

4. Go to this site: www.findtreatment. samhsa.gov.

You’re now looking at the Web site for the Substance Abuse & Mental Health Services Administration (SAMHSA), a division of the U.S. Department of Health and Human Services. This particular page enables you to find a treatment center right in your own backyard.

5. Click on the link to the treatment facility locator.

You get a map of the United States.

6. Click on your state, and a short question- naire pops up.

The nice folks at SAMHSA have already filled in your state.

7. Add your city.

City and state are required, but you can narrow your search by including your zip code, street address, and the radius around your home.

8. Click Continue to get a map of your neigh- borhood with the treatment centers clearly marked.

Try it. Your friends and loved ones will certainly cheer you on. If you don’t have Internet access readily available, try calling 800-662-HELP (4357).

These results are inevitable if you drink too much. Only time heals by enabling you to metabolize alcohol and eliminate it from your body. Hangover remedies or preventives are myths. For example, some people say that you should take an aspirin while drinking to avoid the headache, but the aspirin will intensify the irritation of your stomach lining. To avoid the morning after, drink moderately the night before.

Alcohol and sulfite sensitivity

Sulfur compounds (sulfites) are preservatives widely used to protect the freshness of products such as dried fruits. Some wines also contain sulfur compounds to slow down spoilage by yeasts still active in an aging wine.

Unfortunately, some people are sensitive or allergic to these compounds

and may experience potentially serious reactions if exposed to foods contain- ing sulfites. To avoid problems, the government requires all alcohol products containing sulfites to say so on the label. Sounds sensible to me.

An allergic reaction to sulfites can be life-threatening. If you experience intense itching, hives, swelling of your body, a “tight” feeling in your throat (due to swollen tissues), or breathing problems after drinking alcohol, go directly to the closest emergency room or call 911.

Alcohol and drug interactions

If you drink alcohol, even once in a while, when your doctor hands you a prescription, hand her a request for the lowdown on how the drug may interact with alcohol. The grape and the grain make some drugs stronger and reduce the effectiveness of others.

Table 10-1 lists some of the known interactions between alcohol and a few common prescription and over-the-counter (OTC) drugs. This short list gives you an idea of some of the general alcohol-drug interactions likely to occur, but it’s definitely not complete.

Always check with your doctor — or pharmacist — to be sure that your medication isn’t on the alcohol no-no list.

Rating Alcohol Beverages as Food

People make alcohol beverages from virtually every sugar-containing, carbohydrate food found on the planet, but the most common choices are cereal grains, fruit, honey, and potatoes. All these foods produce alcohol when fermented, but the alcohols have slightly different flavors and colors.

Counting content

No alcohol beverage is 100 percent alcohol. The beverage is always alcohol plus water and, if it’s a wine or beer, some residue of the foods from which it was made. You can tell how much alcohol is actually in an alcohol beverage through the following two ways:

� Alcohol by volume: Alcohol by volume measures the amount of alcohol as a percentage of all the liquid in the container. For example, if your container holds 10 ounces of liquid and 1 ounce of that liquid is alcohol, the product is 10 percent alcohol by volume. A simple equation: Alcohol content÷Total amount of liquid = Alcohol by volume.

The label on every bottle of wine and spirits sold in the United States must show the alcohol content as alcohol by volume (written as 12% alcohol by volume or Alc. 12% by vol. — check out Figure 10-1). When talking to each other, people who make and market alcohol beverages sometimes use the shorthand abbreviation ABV, but this isn’t permitted on beverage labels. For reasons too complicated to explain in less than, say, ten pages, using the term alcohol by volume or proof on beer bottles or cans is optional. Figure 10-1 shows you where to find the ABV on a typical wine label.

� Proof: The label may also show proof, an older way of measuring the alcohol in an alcohol beverage. Proof is two times the alcohol by volume. For example, an alcohol beverage that’s 10 percent alcohol

by volume is 20 proof. Simple equation: Alcohol by volume × 2 = Proof.

Counting calories

On its own, alcohol has no nutrients — zero, zilch, zip — other than energy (7 calories per gram), so distilled spirits such as whiskey have nothing to offer, nutritionally speaking, other than calories. Beer, wine, cider, and other fermented beverages contain some of the food from which they were made, so they also contain small amounts of proteins, carbohydrates, vitamins, and minerals.

Tables 10-3 and 10-4 show the nutrient content for one serving of several types of alcohol beverages. As you can imagine, the amounts listed here are averages. For example, some sweet wines may have higher amounts of carbohydrates (sugars) than this chart shows, but very dry (not sweet) wines have less. Just go with the flow.

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