Honey Dijon Arctic Char

Last week, I got some bad news which I’m hoping I can turn into good news.

The bad news: my cholesterol has hit a personal high of 267 but more concerning, my triglycerides skyrocketed to 253 (‘goal’ is lower than 150 … and in the 10 lab results I’ve tracked since 2002 my triglycerides have NEVER been over 200.)

Also, I now have some “mild kidney insufficiency” which may be related to what’s driving my triglycerides sky-high: a) a diet too high in sugar, carbs and alcohol; and b) not enough exercise.

It’s this – the poor diet and exercise – that I’m hoping I can turn into good news. Which I may be able to, because when I really considered my actions over the past few months I was appalled. In fact, I was surprised and chagrined to realize that since my October 2015 knee surgery I’ve not jumped back onto my near-daily exercise routine (not even close) … and am binge/stress eating chocolate…and wine. Oh, and my new favorite starch, baked sweet potatoes, is probably not helping.

More on the high triglycerides and kidney problem in a more medically-focused post (once I do a bit more research and discuss more fully with my doctor.) With my medical questions stressing me out and wine not the right choice, I decided on Saturday to start righting the medical ship with a lo-co recipe review.

So we went grocery shopping over the weekend and yesterday I made the only salad dressing I like (mustard vinaigrette a la David Tanis – see my love salad post or see recipe below). Then my husband and I grilled bok choy, baked brussels sprouts, and steamed green beans so we have vegetables to easily toss into dinners this week. He then grilled a steak (I know, right?) while I made a new fish recipe that was AMAZING and so very easy: Honey Dijon Arctic Char.

HoneyDijonArcticCharThis fish recipe is a snap – as for the fish itself, if you prefer salmon go for it: both salmon and char are ‘meaty’ fish so they hold up well on the grill. I whipped up the marinade in five minutes and let it absorb on a plate for just 20 minutes instead of 30. We (OK, my husband) grilled it skin side down on medium heat for 5 minutes, and it was an easy flip for another 2-3 minutes for perfectly cooked fish. As you can see, I served it with low-glycemic quinoa (instead of the baked sweet potato that’s been my go to side for the past six months) and baked brussels sprouts and string beans.  Plus ONE glass of wine (I wanted two but…)

Having never made this before AND despising honey, I wasn’t sure I’d like this so I didn’t bother measuring the ingredients. Thus, I was absolutely astonished at how tasty this was. Click the link for recipe details (and for ingredients for 4), which I’ve cut roughly in half, and summarized here:

Honey Dijon Arctic Char / Salmon: for 2-3 servings

Ingredients:

  • 1 large filet of arctic char or salmon, skin on – about 3/4 pound (for 2-3 people, or to have leftovers!)
  • 1/8 cup dijon mustard (I didn’t really measure this)
  • 1/8 cup honey (or this)
  • 1 TB extra virgin olive oil (or this)
  • 2 cloves of garlic – supposed to be minced, I put through garlic press
  • 1 teaspoon fresh thyme (again, no measuring)
  • 1/4 teaspoon white pepper (didn’t measure, used black pepper)
  • juice of half lemon (plus more for serving, if desired)

Directions:

  • Combine mustard, honey, oil, garlic, thyme, lemon juice, salt, and pepper. Using a spoon, coat fillet (both sides) with mixture (if not enough for skin, just throw some olive oil under it). Cover dish with plastic wrap and place into refrigerator for 30 minutes (I just let it sit on counter instead for 20 minutes).
  • On grill pre-heated to about medium, place fish, skin side down (on a fish screen) and cook for 5 minutes. Carefully, turn fish and cook for an additional 3-5 minutes. (It’ll  be done – you can tell it is if the flesh of the fish no longer appears shiny and flakes easily). Remove from grill and serve – with a little extra lemon juice if desired.

Thank you to Derrick Riches on bbq.about.com for the recipe and inspiration. I cannot WAIT to have this fish again tonight. And maybe again for lunch tomorrow – in a salad with my homemade mustard vinaigrette – recipe again here:

Mustard Vinaigrette a la David Tanis– for a TRIPLE recipe: 2 TB Dijon mustard, 6 TB Sherry Vinegar, some finely grated garlic (I use 2 cloves – the recipe asks for 1 1/2 teaspoons) and 9 TB EVOO, salt and pepper to taste. To make: whisk together mustard, vinegar and garlic. Whisk in olive oil. Season with salt & pepper.  Pour into carafe and refrigerate.

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Why You Should Ask Your Doctor About HS-CRP

If you have high cholesterol but no other cardiac disease risks, ask your doctor about the High Sensitivity C-Reactive Protein (HS-CRP) test.

The HS-CRP test is an important predictor of heart disease risk. Actually, as explained in Why You Should Ask For Advanced Lipid Testing, if you are concerned about heart disease risk, you might want to ask your doctor about three key tests: HS-CRP, ApoB and LDL Pattern Type. (While they’re separate tests, all are included in one single Advanced Lipid Panel blood test.)

The HS-CRP test in particular predicts heart disease risk by measuring inflammation in the blood vessels. That the HS-CRP blood test is an excellent predictor of heart disease risk has been widely established. A page on the National Institute of Health about HS-CRP states, “Evidence supporting the hypothesis that elevated CRP levels contributes to increased cardiovascular risk is now available from at least six major prospective studies…”

The HS-CRP is particularly relevant for women. WebMD’s Heart Disease and C-Reactive Protein (CRP) Testing article explains that in the large Harvard Women’s Health study (WHS), “results of the CRP test were more accurate than cholesterol levels in predicting heart problems. Twelve different markers of inflammation were studied in healthy, postmenopausal women. After three years, CRP was the strongest predictor of risk. Women in the group with the highest CRP levels were more than four times as likely to have died from coronary disease, or to have suffered a nonfatal heart attack or stroke compared to those with the lowest levels. This group was also more likely to have required a cardiac procedure such as angioplasty (a procedure that opens clogged arteries with the use of a flexible tube) or bypass surgery than women in the group with the lowest levels.”

That said, if you are already taking a statin or being treated for high blood pressure, the HS-CRP test might not be appropriate. According to Dr. Andrew Weil’s What is elevated C-reactive protein? article, “CRP levels don’t appear to help predict the risk of heart disease in patients already being treated for risks such as high blood pressure or high LDL (“bad”) cholesterol. A 2010 analysis of British data on 4,853 patients found that C-reactive protein levels didn’t yield any more information about the risk of heart disease than LDL (“bad”) cholesterol levels or high blood pressure in patients who already were being treated with a cholesterol-lowering statin drug or with medication to lower blood pressure.”  However, it goes on to say that, “Other physicians, including Dr. Weil, think that all adults should have an hs-CRP test whenever their cholesterol is tested.”

A powerful statement.

My cardiologist appears to agree; at my visit on Christmas Eve, he ordered an advanced lipid panel and an HS-CRP test. There was a mixup on the advanced lipid panel prescription (more on that in another post) so I don’t yet have those results, but I was delighted to see that my HS-CRP test came back with even lower risk than last year.

I was surprised at this result, but apparently should not have been. With a bit of research I found that HS-CRP should be measured over time, as there is high variability in this test. According to the Mayo Clinic, “C-reactive protein (CRP) is an acute-phase reactant and has high intraindividual variability. Therefore, a single test for high-sensitivity CRP (hs-CRP) may not reflect an individual patient’s basal hs-CRP level. Repeat measurement may be required to firmly establish an individual’s basal hs-CRP concentration. The lowest of the measurements should be used as the predictive value.”  I saw this in my own results: in December 2014 my HS-CRP level was 0.8 and in December 2015 it was 0.3.

As both of my HS-CRP measurements are below 1.0 mg/L, that puts me at “lower relative cardiovascular risk” according to the goals printed at the bottom of my test results.  Here are the guidelines:

HS-CRP Guidelines

Do you know your heart disease risk as measured by HS-CRP? If you fall into the category of those for whom the HS-CRP test is a good predictor of heart disease risk (meaning, you aren’t already being treated for heart disease or you have an inflammatory disease), ask your doctor about this simple blood test and get more insight into your heart disease risk.

 

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Why You Should Ask For Advanced Lipid Testing

Controversies in Cardiovascular Medicine is the intriguing title of a 2009 article in the American Heart Association’s Circulation publication.

Stop laughing – cholesterol research can be intriguing!  I’d label the situation frustrating more than intriguing, but here’s what is going on.

The controversy is essentially that advanced lipid testing (explained in Cholesterol Tests Your Doctor Hasn’t Told You About) has been around for 50 years and is a better predictor of cardiovascular disease risk than standard cholesterol blood tests, and yet these ‘advanced’ tests are still not widely prescribed.

In fact, the ‘standard’ cholesterol blood panels (total cholesterol, LDL and HDL) often inaccurately portray risk for many people: those, for example, with normal cholesterol levels who heart attacks. And yet, standard lipid testing is still the norm.  It’s kind of crazy.

As explained in the Circulation article:

“Standard tests of low-density lipoprotein cholesterol (LDL-C) and high-density lipoprotein cholesterol (HDL-C) misidentify coronary heart disease (CHD) risk status in a substantial portion of the population. Tests of apolipoprotein concentrations are superior to standard LDL-C tests, and it can be argued that they should replace standard lipoprotein cholesterol testing.”

The Circulation article goes on to explain that the advanced testing used to be difficult and expensive – but this testing is now more widely available:

“Advanced lipoprotein tests that were previously available only from university research laboratories are now provided by several commercial laboratories.”

Indeed, since Berkeley Heart Lab (which was one of very few offering advanced lipid testing years ago) was bought first by Celera Corp in 2007 and then by Quest Diagnostics in 2011, it is now far easier — and inexpensive — to get advanced lipid testing!

And yet, it’s not widely prescribed.  Sigh.

I just had an advanced lipid panel done in December 2014. It wasn’t easy to get (my internist said not necessary; it wasn’t until I had to see cardiologist for sudden high blood pressure that he agreed it was a good idea). But I’m glad I did because I now have a much better understanding of my personal cardiac disease risk.

Here’s what I learned – and below these key points is some further info about test results that may be pertinent as you consider ASKING FOR advanced lipid testing:

  • My total cholesterol is ‘high’ at 266 and my LDL cholesterol is ‘high’ at 159
  • I have elevated ApoB (score of 123) which contributes to higher cardiac disease risk. But that is offset by other test results.
  • My LDL pattern is type A, which is optimal.  This is the fluffy kind that doesn’t stick to the arteries like the smaller, denser, more dangerous Type B LDL cholesterol.
  • My C-Reactive Protein score of 0.8 is also considered optimal / low risk.

Total and LDL Cholesterol: I find it frustrating that the lab reports still characterize my Total 266 and LDL cholesterol of 159 as ‘abnormal’ or ‘high’ (meaning, high ‘risk’) even though the November 2013 cholesterol guidelines say these scores are not, indeed, high or risky or need treatment. (The new guidelines indicate risk when  LDL>190, along with other factors).

Why do the lab reports not match the new guidelines?  This is inane.

ApoB: I am concerned about my elevated ApoB.  I wrote about apolipoprotein (ApoB) testing and explained why many believe it’s a better predictor of cardiac risk than LDL and total cholesterol testing in ApoB and Cardiovascular Risk.  So this is something I need to keep track of. Interestingly, the lab report says my score is ‘high’ risk and yet, when I dug further, I found a table that showed my personal target is probably <130 (see blog post for details).  Frustration #2 that there are not clear standards.

LDL Pattern Type: The type of LDL cholesesterol you have matters. As explained in the Physican’s Weekly article In The LDL World, Size Matters, roughly half of all people who have heart attacks have ‘normal’ cholesterol levels.  That’s because small sized LDL (Pattern B) can puncture the walls of the arteries and cause plaque buildup – so even ‘normal’ amounts can be dangerous.  If you have high LDL but it’s the Pattern A type which is big and fluffy, that cholesterol bounces off arterial walls so causes less plaque buildup and is thus less dangerous even if you have a ‘lot’ of it.

While I have the preferred / less dangerous Pattern A LDL cholesterol, I found in researching that Pattern B can be modified: if you have Pattern B, you can get it to change to pattern A with diet and exercise!  Which is great.  But that leads me to wonder whether just because I have pattern A now means it sticks (sorry, pun intended) or if it can change to pattern B.  I intend to stay with my lo-co diet and exercise plan, just wondering if I risk changing to Pattern B if I’m not careful. I need to check in with my cardiologist on this.

C Reactive Protein: I was relieved to find my C Reactive Protein score was low. As explained in a Circulation article from 2003 entitled C Reactive Protein: A Simple Test to Help Predict Risk of Heart Attack and Stroke, the C Reactive Protein test is an important measure in assessing cardiac risk. “When measured with new “high sensitivity” CRP assays, levels of CRP less than 1, 1 to 3, and greater than 3 mg/L (milligrams per liter) discriminate between individuals with low, moderate, and high risk of future heart attack and stroke…  Evidence also indicates that individuals with high CRP levels are at increased risk of developing diabetes.”

Now that the Advanced Lipid testing has provided a more in-depth look at my cardiac disease risk, I understand why my cardiologist feels that my 266 Total cholesterol is not terribly concerning. And doesn’t need treatment.

So if you, like me, want a far clearer understanding of your personal risk of cardiac disease, you should ask your doctor to order Advanced Lipid Testing, including scores for:

  • Advanced Lipid Panel Reflex Direct LDL (measures direct LDL and provides the info on particle pattern, number and size)
  • ApoB
  • C-Reactive Protein – the high sensitivity test

Sad to say you’ll probably have to ask your doctor to order Advanced Lipid Testing – he or she is NOT likely to order these tests unless you ask. Which is a shame.

Because as the Circulation article concludes, these tests have been around for 50+ years, are now easily and widely available, and they pick up risk that typical cholesterol panel testing might miss:

“One advantage of ALTs is the greater insight they provide clinicians into individual patient disorders often masked by standard lipid tests considered to be within “normal” ranges.”

It’s important to ask, because advanced lipid testing might reveal that although your cholesterol is not high, you are still at risk. This testing is easy, cheap and could save your life. It will provide you with a more in depth understanding of your cardiac disease risk.

It’s a simple, important question. Ask about advanced lipid panel testing the next time you see your doctor.

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ApoB and Cardiovascular Risk

In Cholesterol Tests Your Doctor Hasn’t Told You About, I briefly describe a cholesterol blood test for Apolipoprotein B (ApoB).  This simple blood test measures the number and size of LDL (bad) cholesterol: it’s an important test if you have high LDL (bad) cholesterol or are at ‘high risk’ of cardiac disease, as it provides a more finely tuned assessment of cardiovascular risk.

In fact, it might be a critical test for those with low LDL (bad) cholesterol – because it can reveal hidden cardiac risk.

While studies show ApoB is a better predictor of cardiac risk, it is not yet a test that is widely prescribed. Indeed, the American Heart Association is waiting for more studies to determine if ApoB is a test doctors should recommend. Personally, I find this frustrating (of course this means nothing as I’m not a doctor, but…) To me, it’s frustrating because this is a simple blood test that provides a detailed risk assessment.

Scientific American’s Heart Health Special Report entitled ApoB – A Better Marker For Heart Attack Risk Than LDL-Cholesterol explains why it’s an effective and important test:

“A high level of low-density lipoprotein (LDL, or “bad”) cholesterol is an important risk factor for a heart attack. Yet about half of the people who develop coronary heart disease have normal or even low LDL cholesterol levels. Some research suggests that a component of LDL—called apolipoprotein B, or apo B—may be more accurate at predicting coronary heart disease.

A Limitation with LDL Cholesterol Testing
The problem with using LDL cholesterol levels to determine heart attack risk is that the test measures only the amount of cholesterol in the LDL cholesterol particles, not the number or size of these particles. Apo B measurements, on the other hand, provide information on the number of LDL cholesterol particles.

For example, people with a higher apo B value than LDL cholesterol value tend to have smaller, denser LDL cholesterol particles. Studies have shown that small, dense LDL cholesterol particles are more strongly associated with heart attack risk than large, “fluffy” LDL cholesterol particles.

The test itself is a simple blood test. It’s easy and cheap: easier, even than the standard cholesterol lipid panel as it does not require fasting.  In fact, the test can be done in conjunction with a standard lipid panel.

Finally, after I visited a cardiologist, I got the ApoB test and my results were, of course, mixed.

Ha! ha ha ha ha ha ha ha

Part of the problem is that since ApoB testing isn’t a standard test there is conflicting info on what the goal ApoB levels should be. My cardiologist was happy with my results because my ApoB is lower than my LDL level, my LDL Pattern is the far healthier Type A / Fluffy LDL, and because my C-Reactive Protein was low risk (more on C-Reactive Protein and LDL patterns in another post.).

But my actual lab report shows my ApoB level of 123 as ‘high risk’ and simply references a desired range of 49-103.  So at 123, I have ‘high’ ApoB.

Ruh Roh.

Who to believe?

Well, it’s simple.  My cardiologist. After a lot of online research (again, I’m no doctor so take all this with a grain of salt), I think the reason my cardiologist is OK with my ApoB score of 123 is because of all those elements I mention above AND ALSO because  I fall into the ‘low risk’ of cardiac disease segment. It turns out that there are different ApoB goals based on a person’s general cardiac disease risk, and the lab report seems not to take this into account.

ApoB goals by risk pool is well explained in Medscape’s emedicine article entitled Apoliprotein B article, in the chart here:

Screen Shot 2015-03-14 at 5.22.44 PM

 

Since my 10 year risk factor via the cardiac disease risk calculator is low (and I also have just 1 risk factor from the ‘old’ way of calculating risk), then it’s probably OK that my ApoB is 123 as it’s lower than 130.

I’m glad I got the ApoB test done – but it’s only because I asked two doctors for it.  If you want a more detailed risk assessment, ask your internist or cardiologist about ApoB testing.

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Do You Have FH?

The cholesterol-watching world is filled to the brim with acronyms and easily confused verbiage.  Who can remember what LDL and HDL stand for – much less which is the good and which is the bad cholesterol?  And then there’s Apo-B and LDL particle size to boot. But today I learned one that was total news to me: FH.

Turns out, FH stands for Familial Hypercholesterolemia which, in a nutshell, is very high LDL (bad) cholesterol that is caused by genetics. A more complete definition is given on The FH Foundation website:

FHlogo“FH is short for Familial Hypercholesterolemia. It is an inherited disorder that leads to aggressive and premature cardiovascular disease. This includes problems like heart attacks, strokes, and even narrowing of our heart valves. For individuals with FH, although diet and lifestyle are important, they are not the cause of high LDL. In FH patients, genetic mutations make the liver incapable of metabolizing (or removing) excess LDL. The result is very high LDL levels which can lead to premature cardiovascular disease (CVD).”

I was amazed to find there’s a site – indeed, an entire foundation – dedicated to high cholesterol caused by genetics.  And a bit miffed – because I know my high cholesterol is genetic… so I can’t believe I didn’t know about this very useful source of information.

And it’s important – because FH is a serious condition and essentially requires choleterol-lowering medication or other intervention:

“Nearly 100% of people with FH will require cholesterol-lowering medications. For some people with FH, more aggressive measures are needed, including LDL-apheresis (a very simple procedure in which LDL-C cholesterol is removed from the blood on a weekly or biweekly basis.)

The American Academy of Pediatrics recommends that if a family has a pattern of early heart attacks or heart disease defined as before age 55 for men and 65 for women, children in that family should have cholesterol testing after the age of 2 years and before age 10.”

All this very sobering information compelled me to track down the excel spreadsheet I use to track my cholesterol results over time.  I was quite pleased to discover that although my high cholesterol is largely caused by genetics, it does not look like I have FH. In my most recent test, I’d brought my LDL (bad) cholesterol down through diet and exercise to 132 (under 130 was the goal before new guidelines were established).  And according to The FH Foundation website, FH is suspected when untreated LDL is above 190 (or 160 in children).

Whew.  Good news for me on the FH front.

Not so good news for me to ‘discover’ that my last cholesterol test was in March 2013.  Um, more than a year and a half ago.  It seems I have “forgotten” to keep track of my cholesterol levels.  Probably because I spent a lot of time this past year at Shake Shack.

So next week, at my annual ob/gyn appointment, I’ll take the blood test order my doctor always gives me and use it to have my cholesterol tested.

And if you have high LDL cholesterol that has not declined with diet and exercise and/or a family history of early heart disease / heart attacks, consider learning more about FH at The FH Foundation site and discuss with your doctor.

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