On Christmas Eve I hosted the family dinner, and I served prime rib. With it I dished up egg-laden Yorkshire pudding, drizzled with gravy. Â "Aren't you a little uncomfortable serving prime rib to Dad?" my brother asked me. "I mean, don't you worry about his heart?"
A couple of years earlier, Dad had had chest pain while walking to the mailbox. One of his biggest coronary arteries was blocked and needed to be opened with a stent. Like all heart patients, he was put on a closely watched diet. And like almost all heart patients, he was also put on a statin. Statins are our most powerful cholesterol-lowering medicines, and they are life-savers for people with heart disease.
Since I am a doctor, Dad lets me look at his cholesterol reports. His cholesterol was never terrible before, but now it is superb.
My brother was gentle when he asked me that question, but he stirred up some guilty feelings in me and he made a good point. Dad is really conscientious about eating healthy foods, but he sure went after my prime rib. It was Christmas Eve, after all. Shouldn't it be okay for him to blow his low-cholesterol diet for a special meal here and there?
My double standard
Doctors recommend diet changes as the first way to lower cholesterol. Your diet needs to minimize animal fats, like cheeses, red meats, whole milk, and butter. You also need to avoid eggs and hydrogenated or partially hydrogenated oils, the soft fat in most processed and chewy snack foods. Sometimes this can reduce LDL (the "bad" cholesterol) by 30 points or so. But cholesterol in the diet is not the whole story. Your liver can manufacture cholesterol, using fatty acids and other raw ingredients from your bloodstream. This means that some people, due largely to genes they inherit, have high cholesterol even when their diet is nearly perfect. Statin drugs block one of the liver enzymes that are used to manufacture cholesterol, so statins can have a dramatic effect.
People with heart disease should have an LDL level that is lower than 100 mg/dL (milligrams per deciliter)--if possible, at or below 70 mg/dL.
When my own patients have seen their cholesterol levels drop lower than their goal after taking a statin, some have asked me whether they can change their diet back to the way it used to be. "Can I go back to eating my cheeses? My eggs and meats?"Â It never feels right to tell a patient to abandon a healthy diet. I usually tell them that they should keep their diet low in cholesterol. After all, with fats come calories, and therefore weight gain. Additionally, without keeping to a healthy diet, a higher dose of drug might be needed. There is a small chance that an increase in dose might introduce side effects.
Another reason I ask my patients to stick with their low cholesterol diet is because I know that so many patients miss their medications. It is hard to be motivated and consistent with your medicines when you are treating an illness that doesn't cause immediate symptoms. It has been estimated that more than one out of four people who are prescribed cholesterol treatment fail to take their statin pills consistently beyond their first two years of treatment. This is true even when the purchase price is fully covered by insurance.
In my dad's case, I have no doubts about his regularity in taking his medicines. Dad has been doing an incredible job with his health. He is eating small portions and exercising almost every day. He eats far more chicken and fish than he used to, keeps up on his salads, and he doesn't eat red meat very often.
I thought about the hundreds of laughs that Dad has had remembering another Christmas, years ago. That Christmas, he watched my cousin stew about whether he was worthy to sit on Santa's lap. "Have you been good?" Â Santa asked. My cousin said that he was usually a good boy, but not always. Santa then said, slapping his knee for drama, "Darn it, boy, you've been good enough!"
I thought my dad had been good enough, too. What's a little prime rib when you've been good all year?
We know from high-quality, long-term studies that low cholesterol numbers relate to good artery health. Some of our studies observe patients and their cholesterol for as long as 15 years. Since cholesterol levels bounce around in the best of us, the numbers that are used in studies are from fasting cholesterol. Fasting cholesterol is affected by your diet overall, but a single meal might not change it very much.
"Fasting" cholesterol isn't exactly the same as "average" cholesterol, but it seems reasonable to think about it in the same way. If you average my dad's cholesterol over the 365 days of last year, my prime rib dinner shouldn't make much of a difference in his average. But is it fair to look only at the averages, or fasting cholesterol for that matter, and the long-term effect of diet choices on your arteries and heart? Or can a single high-fat meal trigger a heart attack?
Are there immediate risks from a high fat meal?
Frankly, there isn't much evidence to say that a single high-fat meal or several of them in a row can put you at any immediate danger, although it is debated.Â Some researchers believe that there is a risk right after eating fats. They say that when there is a high level of circulating fatty acids, there is more "oxidative stress" on the arteries. Essentially, oxidative stress is a chemical shift in the lipids and other substances along the artery wall. Oxidative stress is often present when cholesterol plaques are rough-edged, also called "ruptured", or "unstable"-the type of plaques that trigger a heart attack. Since oxidative stress is often seen when a plaque is unstable, some researchers have worried it is to blame.
Putting these worries aside, we don't have definitive studies that tell us that an occasional high-fat meal can cause danger. It is reassuring to me that short-term studies show the Atkins diet, a diet that includes meats and cheeses, to be safe.
For sure, a one-time eating splurge isn't safe for everyone on a special diet. For example, even a single salty meal has sent patients of mine into the hospital, due to fluid retention, severely high blood pressure, and congestive heart failure. It can take weeks for a person to recover from this kind of set-back. And for someone with diabetes, a meal that has more calories or carbohydrates than usual can throw off blood sugar, sometimes dramatically.
I am not sure a single high-fat meal can cause important harm, at least from its fat and cholesterol. Thinking about this in between our holiday feasts gave me something to chew on, but it kind of killed my appetite. I am thinking next Christmas Eve, whether I have guests or not, I might just stick to salad.
What do you think? Do you think it is reasonable to eat with abandon if you are taking your statin? Will you break your heart-healthy diet for a special occasion?
Mary Pickett, M.D., is an Associate Professor of Medicine at Oregon Health & Science University where she is a primary care doctor for adults. Her field is Internal Medicine. She is also a Lecturer for Harvard Medical School and a Senior Medical Editor for Harvard Health Publications.----------------------------------------------------------------------------------------------------------
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