In women, studies have reported an increase in HDL cholesterol as high as 15% for both premenopausal and post-menopausal women who follow moderate exercise regimens—and the lower the baseline HDL level, the greater the increase.8
Exercise level was inversely associated with cardiovascular risk in the Women’s Health Initiative,9 which followed a cohort of 73,743 women prospectively for an average of 3.2 years. Women at the highest quintile of exercise level reduced their CVD risk by 53% over the lowest quintile, and moderate activity such as walking led to risk reductions similar to those involving more vigorous activities.
Recommend alcohol—or not?
Moderate alcohol consumption—1 to 3 drinks per day, or 15 to 45 g ethanol— improves lipoprotein levels and reduces CVD risk. The flavonoids in red wines also reduce platelet aggregation and clotting tendencies. However, advising a patient to consume alcohol to reduce her CVD risk is controversial; many physicians are reluctant to do so due to obvious concerns over toxicity and dependency.
Response to alcohol may vary by menopausal status. In 1 study,11 pre-menopausal women decreased their LDL cholesterol by 12% (P=.01) after 3 glasses of wine daily for 3 weeks, but there was no significant increase in HDL levels.
In the same study, postmenopausal women increased HDL levels by 12% (P=.03), but their LDL cholesterol decreased only minimally.11
Another study12 in postmenopausal women who consumed 0, 1, or 2 drinks daily (0, 15, or 30 g ethanol) for 8 weeks showed a significant decrease of 4% in LDL cholesterol at 1 drink (15 g), but no significant further decrease at 2 drinks (30 g). In the same study, HDL increased non-significantly at 1 drink (15 g), but increased significantly (5%) at 2 drinks (30 g). There may be a threshold of 30 g ethanol daily for postmenopausal women to benefit significantly from alcohol consumption.
JUDY’S CASE
LIFESTYLE RECOMMENDATIONS
The foundation of Judy’s management should be the triad of weight loss, exercise, and a diet that limits refined carbohydrates and emphasizes fiber, fruits and vegetables, whole grains, and healthy fats (ie, olive, canola, and fish oils).
In prescribing exercise, emphasize quantity over intensity, such as 14 miles of walking weekly or 60 to 90 minutes daily of aerobic activity.
Since she has no history of cardiac symptoms, and low-intensity, high-quantity exercise is advised, she does not need a screening cardiac stress test before beginning her regimen.
Pantethine
Pantethine is an over-the-counter (OTC) nutritional supplement that combines the B vitamin pantothenic acid with the amino acid cysteamine. Although pantothenic acid alone has no lipid-lowering effects, pantethine does: It lowers LDL cholesterol, very-low-density lipoprotein (VLDL) cholesterol, and triglycerides, and raises HDL levels. The exact mechanism of action is unknown, but it is thought to involve primarily the effects of cysteamine on lipid metabolism in the liver.
Recommended dose. At 600 to 900 mg daily, the typical response is an increase of up to 18% in HDL cholesterol and reductions in LDL cholesterol, VLDL cholesterol, and triglycerides of 13%, 20%, and 26%, respectively.13
In a recent US study, pantethine significantly raised HDL-2 cholesterol, the more cardioprotective fraction of HDL, and increased the particle size of LDL cholesterol, rendering it less atherogenic.14
Pantethine also reduces visceral fat. The same study14 reported a significant reduction in visceral fat, a component of metabolic syndrome, as measured by computerized dual-energy x-ray absorptiometry in individuals taking 900 mg daily for 6 weeks. This reduction appears to be primarily an effect of pantothenic acid and had been demonstrated in animal studies.
No side effects. Pantethine is exceptionally well tolerated, with virtually no side effects. An occasional person will experience gastrointestinal upset and diarrhea, which resolve when the drug is discontinued.
Recommend formulations that contain Pantesin (Daiichi Fine Chemicals, New York City), a pharmaceutical grade of pantethine, because extensive research confirms the benefits I have described. Otherwise, make sure the manufacturer is a reputable company, with scientific studies to support its claims of safety, efficacy, and bioavailability.
Nicotinic acid
Nicotinic acid (NA), another B vitamin available OTC as a nutritional supplement, is the most effective agent for raising HDL levels.
Recommended dose. A divided dose of 3,000 mg daily of the immediate-release form of NA can raise HDL levels as much as 30%. Unfortunately, that form of NA has a high incidence of adverse effects, such as flushing, itching, and GI upset.15
Sustained-release NA is generally well tolerated, but somewhat less effective at raising HDL. A lower dose of sustained-release NA (1,000 to 1,500 mg daily) is recommended to avoid liver toxicity and typically leads to HDL increases as high as 20%.15