Americans have a passion for trying to fix things with a pill. Many millions take pills daily to lower their blood pressure or their cholesterol levels.
Millions more swallow vitamins and minerals and "nutritional" supplements in the hope of remaining healthy or slowing the progress of disease. And many believe that the pills will somehow render them immune to the damage wrought by unhealthy habits.
But others have an aversion to medications or fear their current and possible future side effects, especially drugs that must be taken daily for decades to prevent a health problem that may or may not develop. To avoid taking pills, many of these people change their habits to reduce their risk of disease or premature death.
Fifty-two million Americans are candidates for dietary and other changes in habits to lower their cholesterol. Only when that fails to achieve the desired result should drugs be considered.
Richard Erde of Brooklyn smoked his last cigarette on the way to the hospital during a heart attack two years ago at age 53. In a matter of weeks, Mr. Erde was back on the tennis court, his pack-and-a-half-a-day habit behind him and his diet changing rapidly from meat, potatoes and gravy to rice, beans and salad.
On the days he does not play singles tennis, and some days when he does, he cycles or jogs. He is now lean and fit and has his cholesterol checked regularly to be sure that the level of damaging LDL cholesterol stays low and the protective HDL cholesterol remains in a normal range without drugs. He has taken many steps to improve his cholesterol level and thereby lower his risk of a second heart attack.
By quitting smoking and increasing his exercise, Mr. Erde raised his blood level of beneficial HDL cholesterol. By losing weight and cutting way back -- indeed, almost eliminating -- saturated fats, both animal and vegetable, he lowered his total cholesterol, especially the harmful LDL cholesterol. And by adding beans to his diet, he further improved his cholesterol readings.
But for the average person trying to control an elevated cholesterol level through the dietary changes suggested by the American Heart Association, the reduction is almost always a modest one of about 5 percent or 10 percent.
The association recommends initially limiting cholesterol intake to 300 milligrams a day and fat consumption to 30 percent of calories, with no more than 10 percent of calories from saturated fats.
For those who need it, the next level of the association's cholesterol-lowering diet calls for a daily limit of 200 milligrams of cholesterol, 28 percent fat calories and 8 percent saturated fats. The third level cuts intake to 100 milligrams of cholesterol, 22 percent fat calories and 6 percent saturated fats.
Still, such diets are rarely enough to reduce a cholesterol reading of, say, 270 or 300 milligrams per deciliter of blood serum to a level associated with a low risk of developing heart disease.
This "safe" level is said to be below 200 milligrams, though it can inch up above 200 if the contribution of protective HDL cholesterol is very high. The average American man has an HDL level of about 42, and consequently a relatively high risk of heart disease; a level of 60 or more is considered low risk.
Dr. Dean Ornish and the late Nathan Pritikin both demonstrated that adhering to a more austere diet -- one that is nearly or completely vegetarian and contains very little fat of any kind -- can often dramatically lower serum cholesterol. And Dr. Ornish showed that along with daily exercise and stress management, the strict diet can actually reverse some of the damage done to coronary arteries.
It is unlikely that the Ornish regimen would ever gain a wide following among currently healthy Americans whose cholesterol levels are too high. Dietary habits die hard, and the temptations to stray from a low-fat, vegetarian diet are just too prevalent.
But cholesterol-conscious Americans could benefit from a less extreme approach, like the "real" Mediterranean diet, which, though high in fat because it is rich in olive oil, consists primarily of grains, beans, vegetables and fruits, with small amounts of yogurt and cheese daily, fish, eggs and poultry only a few times a week and red meat only a few times a month.
Other cholesterol-improving measures are promising, though less firmly established than a strict diet, regular exercise and stopping smoking.
One is eating many small meals a day, instead of two or three big ones. Another is having an alcoholic drink or two each day. Those who consume moderate amounts of alcohol tend to have higher HDL levels, fewer heart attacks and a longer life expectancy.
Wine, especially red wine, is believed to be most helpful, particularly when consumed with meals. But moderation is the key to health; beyond two drinks a day (8 ounces of wine), the risks of cirrhosis of the liver and other adverse effects rise.