WELLNESS PROGRAM (PART 1). 

As we set out to prevent Breast Cancer, we need to establish a wellness program for our clinic that would be
part of a comprehensive intervention aimed at decreasing cancer risk but also overall mortality risk for our patients.  Estrogenic relative imbalance with noted increase of peripheral estrogenic molecule is suggested in obese patient. This fact is a known Breast cancer risk.  And cholesterol management goes along obesity management.  This discussion will focus on Cholesterol blood level management.

*    LDL=Total Cholesterol - HDL cholesterol - (triglyceride/5)
*    new LDL direct measurement can also be achieved directly without need for fasting.
 ----------------------------------------------------------------------
LDL" Bad cholesterol"
*   normal is below 130mg/dL
*   above this,  lifestyle/diet intervention needed
any time you start intervening, reduce the baseline by 30-40%
To assume almost zero risk for cardiovascular disease reach 40mg/dL or below, but this is may be not a reasonable goal.
-----------------------------------------------------------------------------
In patient with history of Coronary heart disease, peripheral Vascular disease or diabetes, bring cholesterol to less than 100 mg/dL absolutely or better yet 70mg/dL for high risk patients. 
-----------------------------------------------------------------------------------
In general the 5 year risk decrease by 1% for every 2mg/dL decrease in LDL

Medication to decrease LDL, pravastatin, Simvastatin, Ezetimibe, Niacin,
watch liver function test, CPK, C reactive protein, check ANA (associated autoimmune disease) and TSH
Definitely no Fish oil that increases LDL (unless the patient is already on medication decreasing LDL and you aimed at decreasing Triglyceride and aiming at anti-inflmmatory effect).
==========================================================

TRIGLYCERIDES

Normal below 150 mg/dL
150- to 200 mg/dL, is consider Borderline
200 to 499 consider high and needing intervention
more than  500mg is considered critical with impending pancreatitis and Chylomicronemia Syndrome and warrant immediate intervention

Intervention here means
1.Smoking Cessation
2.weight loss program
3. Exercising
4. Reduce Cholesterol intake to less than <200mg/day
5. Reduce saturated fat to less than 7% of total calories daily
6. Increase daily fiber to greater than 10g/day
7. consider increased phyto-Stanols and sterols (greater than 2 g/day)
8. start Nicotic Acid or Gemfibrozil or Fenofibrate, Poglitazone, or Roziglitazone (for Diabetic)
remember Colesevelam increases Triglyceride

for Pioglitazone and Roziglitazone, watch for fluid retention and Congestive Heart Failure!

   ------------------------------REMEMBER, ACHIEVABLE GOAL IS 30-40% REDUCTION-----
NEXT WEIGHT LOSS!