Dietary fats and cholesterol receive considerable attention from the
medical community, food manufacturers and individuals concerned with their
health. Research conclusively demonstrates that elevated cholesterol in
the blood is a significant, and modifiable, risk factor for heart disease.
Subtypes of cholesterol may be independent risk factors or protective for
heart disease. The role of triglycerides is less well defined, but many
feel they also contribute to heart disease. Obesity is also a known
promoter of heart disease. Dietary fat contributes significant numbers of
calories to Americansí daily diets, to obesity and to several forms of
American Heart Association Guidelines
The American Heart Association publishes specific guidelines for dietary
recommendations for fat and cholesterol. The AHA also recommends dietary
and medical interventions for people with elevated cholesterol. The public
now can calculate approximate daily intake of calories, total and
unsaturated fat, cholesterol and fibre as a result of recent FDA food
labelling mandates. Despite the wealth of information available on the
subject, many people are confused by the bold claims and confusing details
regarding control of cholesterol. American Family Physician also has
Patient information: "Goals for Lowering Your Cholesterol".
NIH National Heart, Lung and Blood Institute Clinical Guidelines
The NIH National Heart, Lung and Blood Institute Clinical Guidelines from
the Expert Panel on Detection, Evaluation and Treatment on High Blood
Cholesterol in Adults published in April 2001 have information for both
health care professionals and the lay public. It also includes a 10 year
risk calculator for heart disease and links to all available cholesterol
FAA Policy on Cholesterol Screening
In the early 1990's, the FAA considered measuring blood cholesterol in
pilots in their Notice of Proposed Rulemaking changing FAR Part 67.
Although no disqualification was recommended for elevated cholesterol
levels, values above 300 mg% would have triggered a cardiovascular
evaluation. Numerous objections from many interested parties were
validated and the FAA dropped this proposal from the new FAR Part 67
adopted in September 1996. No blood testing is routinely required nor is
any level of cholesterol disqualifying. However, nearly every
cardiovascular condition requiring evaluation for the FAA includes a
mandatory report of the pilotís cholesterol, triglycerides and glucose
Cholesterol Monitoring for Pilots
The control of blood lipid levels (cholesterol and triglycerides) is an
important step in controlling heart disease, stroke and heart failure.
Anyone interested in their long-term health and well-being should attempt
to reduce their lipid levels if elevated. Pilots traditionally have had
some reluctance to monitor lipid levels and intervene against elevated
levels for fear of adverse effects on their medical certificate. This
reluctance is unjustified. Many methods for lowering cholesterol exist
without using medication. Cholesterol control with dietary changes and
nutritional supplements is not reportable on the FAA Airman's Medical
The FAA currently approves most lipid lowering medications on the market
in pilots who tolerate them well without side effects. FAA physicians look
favourably on pilots who are taking active steps to control their
cholesterol levels as part of any cardiovascular health program. How
should pilots address this issue?
Most physicians recommend obtaining a blood sample to determine baseline
cholesterol, triglycerides and possibly blood sugar levels. To provide a
proper sample, one should fast (nothing to eat or drink except water) for
12-14 hours before the blood is drawn. Abstinence from alcohol for several
days prior to the test may give lowered triglycerides levels. Dietary
changes in the few days before testing have little effect on cholesterol
levels. Monitoring cholesterol levels after instituting medication or
dietary changes is not recommended at intervals less than several months.
Ideally, each blood test for lipids should be done at the same laboratory
to give greater consistency in comparing results.
Most reports of blood lipids are divided into several components. The
total cholesterol is always reported. Levels below 200 mg% are desirable,
lower in some medical conditions. The total cholesterol (TC) is divided
into the high density lipoproteins (HDL), low density lipoproteins (LDL)
and very low density lipoproteins (VLDL). Triglycerides (TG) are reported
HDL is the "good cholesterol". HDL may actually aid in reversing
cholesterol deposits on the lining of the blood vessels. Higher levels
seem to give some protection against heart disease while levels below 30
mg% are an independent risk factor for heart disease. Frequently a ratio
of the TC to the HDL is reported. A TC/HDL ratio of less than 5.0 is
desirable and less than 3.5 is optimum. As the ratio rises, so does the
risk of heart disease.
LDL is the "bad cholesterol". Levels under 130 mg% are acceptable while
those above 160 mg% indicate the need for treatment. Many times, treatment
is appropriate at significantly lower levels of LDL. For those people with
known coronary artery disease, many physicians are recommending lowering
LDL cholesterol levels below 100 mg% to possibly reverse cholesterol
deposits in the arteries. VLDL is infrequently reported as the
significance of this factor is not established.
Triglycerides (TGs) should also be under 200 mg%, but the significance of
elevated levels is not fully explained. Other components of the lipid
profile that are less frequently measured, but associated with heart
disease, include Apoprotein B and lipoprotein (a).
Risk Factor Reduction
Many steps are available for the person with elevated cholesterol
interested in reducing the risk of heart disease.
First, the individual should reduce daily cholesterol intake to less than
200 mg while fats should make up less than 30% of total calories. Many
diet experts suggest a diet containing approximately 20% fats to lower the
risk of several diseases. Diets rich in grains, fruits and vegetables are
ideal. Avoiding unmodified dairy products, rich meats and saturated fats
and oils found in many processed foods reduces fat and cholesterol. Low
fat alternatives are available. Reading the nutritional labels on foods is
enlightening and possibly surprising. Poly- and mono-unsaturated oils may
actually lower cholesterol.
Publicity for the high protein, low carbohydrate diets (Atkins) in
November 2002 at the American Heart Association Annual Scientific Meeting
generated much confusion about a proper diet. For information on the AHA's
current position, see the AHA Statement on High-Protein, Low-Carbohydrate
Diet Study Presented at Scientific Sessions.
Exercise is an important step in lowering total cholesterol and raising
Smoking cessation will also raise HDL. One to two ounces of alcohol (a 12
oz. beer, one glass of wine or a single mixed drink) daily may be helpful
in improving cholesterol. More than this amount is harmful.
Soluble fibre and omega-3 fatty acids will improve cholesterol profiles.
Good sources of omega-3 fatty acids include fatty fish products (salmon)
and flax seed oil. Flax seed oil is an excellent source of essential fatty
acids in the diet, including the very desirable omega-3 and omega-6 fatty
Adequate dietary intake of certain vitamins including niacin, vitamin E,
some B vitamins and folate may be protective. The VFS article on Vitamins
and Minerals has expanded discussions on each of these essential dietary
components. Also see an article in American Family Physician on
Alternative Therapies: Part II. Congestive Heart Failure and
Hypercholesterolemia. The Agency for Healthcare Policy Research did not
find evidence for reduction in heart disease with use of antioxidant
supplements in its Evidence Report/Technology Assessment: Number 83,
"Effect of Supplemental Antioxidants Vitamin C, Vitamin E, and Coenzyme
Q10 for the Prevention and Treatment of Cardiovascular Disease"
Increasing fibre intake in the diet may also lower cholesterol. Research
indicates that soluble fibre may interfere with the absorption of
cholesterol in the intestine and significantly lower cholesterol and
triglycerides levels. Fruits, grains and vegetables are high in fibre. The
average American diet includes about 5-10 grams of fibre daily. The
recommended amount is 25-35 grams.
Many people find it hard to increase their fibre intake to meet these
recommendations with non-medicinal nutritional supplements. These
supplements may be very effective in lowering cholesterol. They are not
reportable to the FAA or your AME as a medicine. Consult with your
personal physician or a preventive medicine specialist for details on
available supplements. The Virtual Flight Surgeons article on Herbal
Medications and Nutritional Supplements has an expanded discussion of the
role of dietary fibre. Also see an article in the Federal Air Surgeon's
Medical Bulletin by Dr. Glenn Stoutt, Just About Everything You Need to
Know About Fibre in Your Diet
Next, the person should avoid all tobacco products and participate in a
program of regular aerobic exercise. Discuss an exercise program with your
physician if you do not already engage in regular activity. These steps
will lower the total cholesterol and raise the HDL. The TC/HDL ratio may
drop significantly. Weight reduction will also help lower total
cholesterol. See the VFS articles on Smoking Cessation and Tobacco Abuse,
Obesity and Weight Control. Nutritional supplements and vitamins may also
play an important role in cholesterol reduction.
Cholesterol Lowering Medications
For those who continue to have elevated lipids despite non-pharmacological
steps or those who have other risk factors for heart disease or marked
elevated lipid levels, intervention with medications may be prudent.
Several categories of medications are available. The selection should be
determined after discussion with your physician about your lipid profile,
co-existing medical conditions, family history, lifestyle and costs and
side effects of the medications.
HMG Co-A Reductase Inhibitors -
The HMG Co-A reductase inhibitors, also known as "statins", are the most
widely used class of medication to lower cholesterol. They work by
blocking an enzyme that converts dietary fats into cholesterol in the
liver. The statins are relatively recent entries into the market, but
their popularity is due to their excellent tolerance and tremendous
effectiveness. They have very few side effects and may be taken once daily
in most cases. There is some potential to elevate liver enzymes so some
physicians will add liver testing to repeat cholesterol testing. The major
drawback, as with any new and successful drug, is their cost. Examples
include pravastatin (Pravachol), lovastatin (Mevacor), simivistatin (Zocor),
fluvastatin (Lescol) and atorvastatin (Lipitor). The newest statin drug is
Crestor (rosuvastatin) which is authorized by the FAA.
The FDA announced a recall of one "statin", cerivastatin (Baycol), on
August 8, 2001. Manufacturer Bayer AG announced that 31 deaths have been
associated with its' use, primarily in the high dosage form or when
combined with another cholesterol medication called gemfibrizol. See the
FDA Baycol Information Page.
An article in the May 2002 issue of Neurology raised the possibility of
the statin medications leading to an increased risk of neuropathy (nerve
damage). The study was conducted by a Danish physician, but the results
have yet to be reproduced in the US.
Another potentially significant side effect of some statins is myositis
(muscle damage, weakness and pain). The October 1, 2002 issue of Annals of
Internal Medicine published an article documenting muscle damage in four
patients using statins who had normal levels of CK, an enzyme usually used
to monitor for myositis. The National Heart Lung and Blood Institute
published Guidelines and a Clinical Advisory on the use of statins.
Overall, the benefits of statins far outweigh the risks of their use in
most people with elevated cholesterol.
Niacin is a B vitamin that is effective in lowering LDL, TC, TG and TC/HDL
ratio. It also significantly raises HDL. All of these effects are
desirable. The major advantage is that it is inexpensive and effective.
The disadvantage is that it may cause skin itching and flushing after
taking even moderate doses. This effect is reduced by taking a single
aspirin 30 minutes prior to the niacin.
Liver injury is also possible as in the statins and monitoring of liver
function is recommended. Crystalline niacin does not seem to cause liver
injury, which is primarily associated with long acting or slow release
forms of niacin. Recent products that release niacin slowly to decrease
the flushing are Niaspan, Slo-Niacin, Niocor and Nicolar, but require
regular monitoring of the liver to detect early damage. Niacin doses of
200-400 mg per day may be effective in lowering cholesterol levels, while
dosages of up to 2000 mg per day may be used in serious cases of elevated
lipids. Niacin is available as a nutritional supplement without a
prescription. See the VFS article on Vitamins and Minerals for more
information on niacin benefits.
Bile Acid Sequestrants
Bile acid sequestrants act much like soluble fiber in the intestine. These
products bind bile acids that allow dietary fat to be absorbed and
processed into cholesterol. They have been on the market a long time. They
are in powder form and may need to be mixed with juice to take in a
palatable form. The major limiting factor is their tendency to cause
stomach upset, bloating and flatulence. These side effects are minimized
by gradually increasing the dosages. Bile acid sequestrants may also block
the absorption of some medications. They may raise TG levels slightly.
Examples include cholystramine (Questran) and colestipol (Colestid).
Gemfibrizol and Clofibrate
Fibric acid derivatives were some of the earlier triglyceride lowering
medications. These medications are effective in lowering triglycerides,
with much less effect on cholesterol. The major side effect is the
potential for gallstones and gallbladder disease. Gemfibrozil (Lopid) or
clofibrate (Atromid-S) have variable effects on LDL cholesterol. Use of
gemfibrozil in combination with high dosages of the FDA recalled
cerivastatin (Baycol) has been linked to patient deaths. Gemfibrozil used
alone has not been associated with deaths.
Zetia (ezetimibe) is in a new class of cholesterol and triglyceride
lowering medication that can be used with other medications for the same
condition. It was approved by the FDA in October 2002 authorized for use
in pilots by the FAA in October 2003. It's mechanism of action is to
selectively inhibit absorption of cholesterol from the small intestine,
reducing uptake by 54%. See a review of this medication in American Family
FAA Reporting Requirements
The FAA will approve all medication categories listed above after a ground
testing period of several days free of side effects. Reporting of the use
of the medication is required at the time of the next FAA medical
examination. Report in Section 17 of the FAA Application for Airman's
Medical Certificate, Form 8500-8, under Medications Used.
Controllers should report to the Regional Flight Surgeon before returngin
to safety sensitive duty. Use of fibre, non-prescription niacin and
nutritional supplements are not reportable to the FAA.
New Food Products to Lower Cholesterol
A new butter-margarine substitute which may lower cholesterol levels has
been approved by the FDA recently. The product, called "Take Control" from
Lipton contains unsaturated fat chains, called sterols, derived from
soybeans. These phytonutrients are acknowledged as "Generally Recognized
as Safe" and may help lower cholesterol levels.