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Cholesterol Control The Facts About the Fats

On this page: Cholesterol | What Affects Cholesterol Levels | Understand Food Labels | Substitute Good Fats for Bad Fats | Fish Oil | Medications
Other pages: Cardiac Anatomy

Cholesterol: Up with the Good and Down with the Bad

A cholesterol level is measured by a simple blood test that is ordered by your health care provider. You should fast for 9-12 hours before having your blood cholesterol checked.

Everyone age 20 and older should have their cholesterol measured at least once every 5 years, more often as you get older.  It is best to have a blood test called a “lipoprotein profile”. 
Atherosclerotic plaque

Cholesterol

Cholesterol is a waxy, fat-like substance made in the liver, but also is found in certain foods.  There are several types of cholesterol, including low-density lipoproteins (LDL) and high-density lipoproteins (HDL). 

Throughout life, beginning in childhood, there is a gradual build up of cholesterol and other substances on the inner lining of an artery referred to as atherosclerotic plaques. Over time, these plaques can harden and narrow an artery enough to slow or even block blood flow. The illustration to the right, courtesy of 3D Science.com, shows the build up of an atherosclerotic plaque on an artery wall.

Atherosclerotic plaques are often unstable and can rupture into the vessel lumen causing a blood clot to form.  This can result in a sudden blockage of an artery.  This is often the process by which people experience heart attacks or strokes.  In some people, the first sign of atherosclerosis might be a heart attack or even sudden death.

As the level of blood cholesterol increases, so does the possibility of blocking the blood flow in the arteries due to cholesterol plaque build-up. the level of cholesterol in the blood can be measured by a blood test: 

        • Total Cholesterol Levels:
          • 200 mg/dL or below=good;
          • 200 to 239=borderline high;
          • 240 or above=high.

LDL Cholesterol (bad)

LDL cholesterol is considered "bad" cholesterol because excessive levels of LDL can lead to a build up of thick, hard deposits called plaque on the inside of the blood vessel wall. (See yellowish plaque build up in wall of blood vessel in illustration to right, Courtesy of 3DScience.com) These plaques also contain various types of cells often associated with inflammation as the body tries to rid itself of this abnormal buildup. When it comes to bad cholesterol, the lower the better. The less LDL there is in the blood, the less the risk of heart disease.

  • An LDL level of 100 or less is usually recommended, but 70 or less is optimal, especially in some patients at high risk of coronary heart disease.
  • Saturated fats and transfatty acids in the diet raise the LDL cholesterol levels in the blood.

HDL Cholesterol (good)

HDL cholesterol is referred to as "good" cholesterol because it lowers your risk of heart disease and stroke. HDL protects your arteries from plaque buildup by acting as a scavenger that removes cholesterol from the arterial walls and carries it back to the liver, which leads to its removal from the body.  The higher the blood level of HDL-cholesterol, the better.  Conversely, low levels of HDL increase the risk of heart disease and stroke. 

  • HDL Blood levels of:
    • less than 40 mg/dL are a major risk factor for heart disease. 
    • 60 mg/dL and above is considered protective against heart disease.(1)
  • Smoking lowers HDL levels;
  • Exercise increases HDL levels.(12)  

 

Triglycerides

Triglycerides can also raise heart disease risk. Triglyceride levels that are borderline high or high may need treatment in some people.

  • borderline high (150-199 mg/dL)
  • high (200 mg/dL or more)

Factors that affect cholesterol levels:

  • Diet One of the most important determinants of blood cholesterol level is fat in the diet--not total fat, but specific types of fat.  Bad fats increase the risk for certain diseases and good fats lower the risk.(1)  See below.

  • Weight: Being overweight can increase cholesterol levels.  Losing weight can help lower the LDL (bad) and total cholesterol, as well as increase HDL (good) cholesterol. (Excess weight is also a risk factor for heart disease)

  • Exercise: Regular, continuous, aerobic exercise can raise HDL (good) cholesterol.  Exercise for 30 minutes/day on most days is generally recommended for most people.  For those unable to tolerate 30 minutes at a time, exercise can be broken up into three-10 minute sessions per day.  Try to gradually work up to 30 minutes per day, if possible.  Activity should be continuous, with a low to moderate intensity. Continuous, aerobic exercise includes walking briskly, swimming, running, jogging, climbing stairs, and bicycling on a regular or stationary bicycle.

  • Smoking: Cigarette smoking is the most important preventable cause of premature death in the United States(7).  In addition to the damaging effects on the lungs, smoking also greatly affects the heart and blood vessels.  Smoking lowers HDL (good) cholesterol, increases blood pressure, decreases exercise tolerance and increases the tendency for blood to clot. Cigarette smoking alone, is a major cause of coronary heart disease, which leads to heart attack.  If you smoke, quitting is the single best thing you can do to reduce your cardiac risk.

  • Age and Gender: Cholesterol levels rise with age.  Menopause also adversely affects women's LDL (bad) cholesterol levels. Before menopause, women tend to have lower total cholesterol levels than men of the same age.  After menopause, women's LDL levels tend to rise.

  • Heredity: High blood cholesterol levels can run in families.

  • Other causes: Certain medications and medical conditions can cause high cholesterol.

 

Arrow pointing to "Substitute"Substitute good fats for bad fats in your diet

One of the most important determinants of blood cholesterol level is fat in the diet--not total fat, but specific types of fat.  Bad fats increase the risk for certain diseases and good fats lower the risk.(1)  Fats and oils are mixtures of fatty acids.  Each fat or oil is categorized as  "saturated", monounsaturated" or "polyunsaturated," depending on what type of fatty acid in it predominates.(4)


Bad Fats:  increase the risk for heart disease and stroke

Saturated Fats In general, limit to 15 to 20 gms/day; for people with diabetes or heart disease, limit saturated fat to <10 grams/day. For people with elevated LDL-cholesterol, limit to 15 gms/day.(2) Saturated fats are usually a bigger problem than the cholesterol we consume.  These fats are mainly animal fats and are found in meat, lard, butter, whole milk dairy products (cheese, milk and ice cream) egg yolks, tropical oils-coconut, palm, and palm kernel oil.  Saturated fats are usually solid at room temperature.

Trans-fatty acids (try to eliminate from diet) Trans fats have been found to be far worse than saturated fats when it comes to heart disease.  They raise (bad) LDL cholesterol, and lower (good) HDL cholesterol.  As of Jan 1, 2006 food manufacturers will be required to list trans fat on nutritional food labels. This will make it easier for consumers to avoid these fats.  In the meantime, look at the ingredient list on the food label. If the ingredient list includes the words “shortening,” “partially hydrogenated vegetable oil” or “hydrogenated vegetable oil,” the food contains trans fat. Because ingredients are listed in descending order of predominance, smaller amounts are present when the ingredient is close to the end of the list(5). Trans fatty acids are produced from partially hydrogenated oils and are used to help foods stay fresh on the shelf or to produce a solid fat product, such as margarine.  French fries, donuts, cookies, chips and other similar snack foods are high in trans fatty acids.   In general, trans fats are often found in commercially prepared baked goods, stick margarines, snack foods, processed foods, many fast foods and commercially prepared fried foods (4).

Cholesterol (limit to <300 mg/day) One large whole egg is about 212 mg of cholesterol.  Note: If LDL-cholesterol is above the desired goal, it is recommended that you limit cholesterol intake to <200 mg/day (2).

Good Fats:  Unsaturated fats lower the risk of heart disease and stroke

Unsaturated fats are found in products derived from plant sources, and are found in vegetable oils, nuts, and seeds.  There are 2 main categories of unsaturated fats: Polyunsaturated fats & Monounsaturated fats.  Both are liquid at room temperature--polyunsaturated fats are also liquid in the refrigerator, but monounsaturated fats start to solidify at refrigerator temperatures. 

Polyunsaturated fatty acids (PUFAs): There are two major classes of PUFAs -- the omega-3 and the omega-6 fatty acids. Most American diets provide at least 10 times more omega-6 than omega-3 fatty acids. There is now general scientific agreement that individuals should consume more omega-3 and fewer omega-6 fatty acids for good health.(24)

  • Omega-3 fatty acids are thought to reduce cardiovascular disease risk by  lowering triglyceride levels, decreasing the growth rate of atherosclerotic plaques, decreasing risk of sudden death and arrhythmias, decreasing thrombosis (blood clots), improving arterial health, and by lowering blood pressure. (13)   Omega-3 fatty acids are found in a variety of dietary supplements. For example, products containing flaxseed oil provide ALA, fish-oil supplements provide EPA and DHA, and algal oils provide a vegetarian source of DHA.

    • EPA and DHA: Fatty fish (mackerel, salmon, sardines, swordfish and albacore tuna) are high in two kinds of omega-3 fatty acids, EPA and DHA (eicosapentaenoic and docosahexaenoic acids).

    • Alpha-linolenic acid (ALA): A third kind, alpha-linolenic acid, is less potent. It comes from soybeans, canola, walnut and flaxseed and oils made from those beans, nuts and seeds. Alpha-linolenic acid can become omega-3 fatty acid in the body; recent studies have found that it seems to lower the  risk of heart disease. The extent of this benefit is not yet completely established with more research recommended by the AHA.  At this point, the AHA has indicated that 1.5 to 3 grams per day of alpha-linolenic acid seems beneficial(6) Alpha-linolenic acid is found in a variety of green leafy vegetables, some types of nuts (especially walnuts), soybeans, canola oil, flaxseed oil and flaxseed supplements.

  • Omega-6 fatty acids: Linoleic acid (LA) is an omega-6 fatty acid and is converted in the body to arachidonic acid (AA). Both fatty acids alpha-linolenic acid (ALA) and linoleic acid (LA) must come from the diet because they cannot be made by the body. As previously mentioned, it is thought that individuals should consume more omega-3 and fewer omega-6 fatty acids for good health. It is not known, however, whether a desirable ratio of omega-6 to omega-3 fatty acids exists for the diet or to what extent high intakes of omega-6 fatty acids interfere with any benefits of omega-3 fatty acid consumption. LA is found in many foods consumed by Americans, including meat, vegetable oils (e.g., safflower, sunflower, corn, soy), and processed foods made with these oils. The Institute of Medicine has established Adequate Intakes for ALA (1.1-1.6 g/day) and LA (11-17 g/day) for adults but not for EPA and DHA.(24)

The American Heart Association (AHA) currently recommends that everyone eat at least 2 servings of fish a week.  It's important to note that fried white fish commonly found in fast food fish sandwiches and fish sticks lack the beneficial fatty acids and may actually increase the risk of atherosclerosis.(16) Also, mercury consumption can be a concern with certain fish. read more about Mercury from the American Heart Association.

Fish Oil Supplements:Fish oil supplements provide EPA and DHA.  In the U.S., there currently is no official recommended intake for EPA and DHA in healthy people.

  • Prescription Fish Oil Supplements: Recently a prescription fish oil supplement, Lovaza, has been tested and approved by the FDA. Lovaza is for adults and is to be used along with a low-fat and low-cholesterol diet to lower very high triglycerides (fats) in the blood. It is called a lipid-regulating medicine and is made of omega-3 fatty acids. One capsule yields almost twice the concentration of both EPA and DHA than most brands available over-the-counter.  The usual therapeutic dose of LOVAZA is 4 capsules to be taken all at once or divided into two doses, two capsules two times daily. It is not for women who are pregnant or breastfeeding. The Lovaza website lists more about side effects and precautions. 

  • Over-the-counter fish oil supplements: There are many fish oil supplements available over-the-counter, but the problem is that most herbs and supplements have not been thoroughly tested by the FDA for purity and quality and thus there is a lack of consistency in dose and quality of many of these products that appear on the market. In fact, what appears on the label may not necessarily be in the bottle.  One independent company, that is used by many health care professionals, is ConsumerLab.com.  It provides independent testing results online about vitamins, supplements, and nutrition products to consumers and healthcare providers. They have apparently recently completed testing of 57 different fish oil products sold in the U.S. claiming to contain EPA and/or DHA and tested them for their levels of omega-3 fatty acids, mercury, lead, PCBs, and signs of decomposition. They found varying levels of quality and these results are available online for an annual subscription fee.

More about fish oil supplements:

  • Taking fish oil supplements should be done in consultation with your physician.
  • Fish oils are best tolerated when taken with meals, and, if possible, should be taken in divided doses such as dividing the total dose in half and taking it twice daily.
  • Caution: High intakes could cause excessive bleeding in some people. Of particular concern are people with bleeding disorders such as hemophilia, and those taking blood thinners, such as Coumadin (warfarin) heparin, Lovenox, or aspirin, and those expecting to undergo surgery.

Two studies using fish oil supplements:

    • One large study found that by getting 1 gram per day of omega-3 fatty acids over a 3 1/2 year period, patients who had previously had a heart attack, could lower their risk of dying from heart disease by 25%.  The participants in the study obtained their omega-3s from a capsule.  Getting a gram/day from fish would mean eating a serving a day of fatty fish. (18)  
    • In a study of 18,000 patients with hypercholesterolemia and a history of coronary artery disease, researchers found the addition of fish oil to statins (cholesterol lowering medication such as Lipitor) reduced the occurrence of major coronary events by 19% over statins alone. Lancet 2007; 369: 1090-98.

Oils:

  • Flaxseed oil is the best oil to use.  It contains a very low omega 6 to omega 3 ratio (0.24--anything less than 3.0 is healthful) and it is composed mainly of polyunsaturated fats (66% of the total fats) which will help lower blood cholesterol.  Flaxseed oil should be used without cooking, as in salad dressing, as high heat destroys the healthy fatty acid.  Flaxseeds can be taken as a supplement or sprinkled in cereal or salads.  They have a mild, nutty flavor and are easy to include in your diet.  Flaxseeds are a good alternative to  flaxseed oil and is also a good source of fiber.  Both of these products can be found in grocery stores. Flaxseed oil supplements can affect blood clotting and should be taken only in consultation with your physician.

  • Canola oil is the 2nd best oil to use.  It has a low ratio (2.0) of omega 6 to omega 3; it is composed mostly of monounsaturated fats and will also help lower cholesterol, but not as much as flaxseed oil.

  • Olive oil has only a marginal omega 6 to omega 3 fat ratio of 13.1, but it does have healthy, cholesterol-lowering monounsaturated fats.  If you like using this oil it is best to blend olive oil with either canola or flaxseed oil.

Nuts: Walnuts are the best nuts and have the best Omega 6 to Omega 3 ratio.  Avoid eating nuts by the handfuls, however; more is not better in this case. In general, it's best to limit to one tablespoon of chopped nuts per day.

Fish: Fish are an important source of the polyunsaturated fat known as omega-3 fatty acid.  Fatty fish (mackerel, salmon, sardines, swordfish and albacore tuna) are high in two kinds of omega-3 fatty acids, EPA and DHA (eicosapentaenoic and docosahexaenoic acids).

Green leafy vegetables contain alpha-linolenic acid. According to a study reported in the Annals of Internal Medicine, 2005, low-fat diets that include high amounts of whole grains, beans, vegetables and fruits offer twice the power to reduce cholesterol as diets that are simply low in fat.

Protein: Choose low-fat or lean meats, poultry, fish, beans, peas, nuts and seeds. Baking, broiling and grilling are recommended, avoiding fried foods. High-quality proteins from vegetable sources such as beans are good substitutes for animal sources of protein.(12)  Fish is also a good protein.

Instead of butter, add plant stanols and sterols to your diet. These are found in the cholesterol-lowering spreads Benecol, Take Control, Smart Balance Plus and in the dietary supplement Benecol SoftGels.  These spreads are excellent alternatives to butter--but don't overdo it, as many do contain some saturated fat.


Read and Understand Nutritional Food Labels to find out what you are eating!
Read the "Nutritional Facts" label and not just the promotional words.  Food advertised as containing "No cholesterol" can still contain large amounts of harmful saturated fats and transfatty acids.
Below (on the left) is a sample label  from a box of breakfast cereal:

Nutrition Facts
Serving Size 1 cup (30g), Servings Per Container About 25
Amount Per Serving
Note the serving size as it varies  considerably between  products! The label to the left  refers to the amount of nutrients in 1 cup of this food. There are 25 cups of food in this container.
Calories 120 Calories: In general, 40 calories is low, 100 is moderate, and 400 is high for 1 serving
     Calories from Fat 15  
 
 

% Daily
 Value

% Daily Value is based on a 2,000 calorie per day diet.  Daily Values (DVs) are used on food and dietary supplement labels to indicate the percent of the recommended daily amount of each nutrient that a serving provides. DV replaces the previous designation of United States Recommended Daily Allowances (USRDAs).
Quick guide: 5% or less of the daily value is low, 20% or more is high.
Total Fat
1.5g

2%

There is 1.5 g of total fat in 1 cup of this cereal which is 2% of the recommended daily amount for a 2,000 calorie diet.  There is actually no optimal amount of total fat in a healthy diet. One of the most important determinants of blood cholesterol level is fat in the diet--not total fat, but specific types of fat.  Bad fats increase the risk for certain diseases and good fats lower the risk.(1)  .

Saturated
Fat 0g

0% There is no saturated Fat-(bad fat) in this cereal.  Saturated fats are usually a bigger problem than the cholesterol we consume.  In general, limit to 15 to 20 gms/day; for people with diabetes or heart disease, limit saturated fat to <10 grams/day. For people with elevated LDL-cholesterol, limit to 15 gms/day.(2) 
Trans
Fat 0g Trans fats are found in deep-fried foods, bakery products, packaged snack food, margarines, and crackers, and consumption of these foods significantly raise levels of LDL (bad) cholesterol , reduce HDL (good) cholesterol, and increase triglyceride levels.
Trans Fat--bad fat--try to eliminate from diet altogether. The consumption of unhealthy trans fats is remarkably prevalent in the United States yet the adverse health effects of these fats are far more dangerous on average than those of food contaminants or pesticide residues. As of Jan 1, 2006 food manufacturers will be required to list trans fat on nutritional food labels. This will make it easier for consumers to avoid these fats. However, in certain foods, these labels can be misleading. For example, producers of foods that contain less than 500 mg of fatty acids per serving are allowed to list the content as zero on the packaging. But in multiple servings, consumers might unwittingly consume substantial amounts of the trans fats. Read the ingredients list to find clues to hidden trans fats: the words "partially hydrogenated vegetable oils" means the product contains trans fats.

Another problem with hidden trans fats is that food labels are rarely seen in restaurants, bakeries, and other retail food outlets.

Poly-
unsaturated
Fat 0.5g
  Polyunsaturated Fat--good fat. There are 2 main categories of unsaturated fats: Polyunsaturated fats & Monounsaturated fats. Both polyunsaturated and monounsaturated fats lower blood cholesterol when substituted for saturated fats in the diet.(2)
Mono-unsaturated
Fat 0.5g
  Monounsaturated Fat--good fat
Cholesterol
0mg
0% Cholesterol:  limit to <300 mg/day   One large whole egg is about 212 mg of cholesterol.  Note: If LDL-cholesterol is high, it is recommended that you limit cholesterol intake to <200 mg/day (2).  Note: Food advertised as containing "No cholesterol" can still contain large amounts of harmful saturated fats and transfatty acids.
Sodium
210 mg
9% Sodium  Research shows that eating less than 2,300 milligrams of sodium (about 1 tsp of salt) per day may reduce the risk of high blood pressure. Most of the sodium people eat comes from processed foods, not from the saltshaker.
Total Carbohydrate 24g 8% Carbohydrates contain about 4 calories per gram. This product contains 24 grams, thus 96 of the total 120 calories are from carbohydrates.
Dietary
Fiber 2g
Soluble
Fiber 1g
 
8% This cereal provides 8% of the recommended daily amount of fiber.  Fiber is part of plant foods that is not digested. In general, an excellent source of fiber contains five grams or more per serving, while a good source of fiber contains 2.5 – 4.9 grams per serving. The recommendation is to eat 25-30 grams of fiber per day. To achieve this goal, increase gradually to avoid stomach irritation. The grams of sugar and fiber are counted as part of the grams of total carbohydrate. If a food has 5 grams or more fiber in a serving, subtract the fiber grams from the total grams of carbohydrate for a more accurate estimate of the carbohydrate content. (10)
Sugars 11g
Sugars: If you are concerned about your intake of  sugars, the amount of sugar should not be more than 1/2 of the total carbohydrates.  For example, a food with 24g of total carbohydrate with 23g from sugars, should be avoided.
Sugar
alcohols 11g
Sugar alcohols A sugar alcohol is neither sugar nor alcohol but is actually a carbohydrate with a chemical structure that partially resembles a sugar and partially resembles an alcohol. Another term for sugar alcohols is polyols. They are a group of caloric sweeteners that are incompletely absorbed and metabolized by the body and consequently contribute fewer calories than sugars. The sugar alcohols or polyols commonly used in the United States include sorbitol, mannitol, xylitol, maltitol, maltitol syrup, lactitol, erythritol, isomalt, and hydrogenated starch hydrolysates. Their caloric content ranges from one-and-a-half to three calories per gram compared to four calories per gram for sugars. Some of these polyols are sweeter than sugar so you can use less to get equal sweetness and, as a result, consume fewer calories. Use of sugar alcohols in a product does not necessarily mean the product is low in carbohydrate or calories. And, just because a package says "sugar-free" on the outside, that does not mean that it is calorie or carbohydrate-free. Always remember to check the label for the grams of carbohydrate and calories. (10)

Due to their incomplete absorption, the polyol sweeteners produce a lower glycemic response than glucose or sucrose and may be useful for people with diabetes. Sugar alcohol-sweetened products may have fewer calories than comparable products sweetened with sucrose or corn syrup and hence could play a useful role in weight management.

Protein 3g   Protein contains about 4 calories per gram.  Thus 12 calories in this product comes from protein. 
Vitamin A 10%

Vitamins: This cereal provides 10% of the recommended daily value of Vitamin A and Vitamin C for a 2,000 calorie diet.

Vitamin C 10%
Ingredients Whole grain oats, sugar, oat bran, modified corn starch, honey, brown sugar syrup, salt, ground almonds,  iron, Vitamin C

Ingredients are listed at the end in descending order by weight, meaning the first ingredient makes up the largest proportion of the food.

Avoid: Check the ingredient list to find ingredients you'd like to avoid, such as coconut oil or palm oil, which are high in saturated fat. Also try to avoid hydrogenated oils that are high in trans fat. They may not listed by total amount on the label, but you can choose foods that don't list hydrogenated or partially hydrogenated oil in the ingredient list at all.

Look for heart-healthy ingredients: The ingredient list is also a good place to look for heart-healthy ingredients such as soy; monounsaturated fats such as olive or canola oils; or whole grains,like whole wheat flour and oats. The FDA recommends substituting whole grains for refined grains (white bread, etc.) Consuming at least 3 or more ounce-equivalents of whole grains per day can reduce the risk of several chronic diseases and may help with weight maintenance. For many whole-grain products, the words "whole" or "whole grain" will appear before the grain ingredient's name. The whole grain should be the first ingredient listed. Wheat flour, enriched flour, and degerminated cornmeal are not whole grains. The Food and Drug Administration requires foods that bear the whole-grain health claim to contain 51 percent or more whole-grain ingredients by weight per reference amount and be low in fat.(2)

Sugars: If you are concerned about your intake of  sugars, make sure that added sugars are not listed as one of the first few ingredients. Other names for added sugars include: corn syrup, brown sugar syrup, high-fructose corn syrup, fruit juice concentrate, maltose, dextrose, sucrose, fructose, lactose, honey, maple syrup, molasses and turbinado.

Evaluating your risk of complications from abnormal cholesterol levels

To determine whether you need medication, your doctor looks at your total cholesterol, LDL, HDL, and triglyceride levels and considers these with any risk factors you might have for heart disease.  The following reference and tool from the National Institute of Health is often used by physicians in assessing cardiac risk: Heart Disease Risk Calculation Tool  and ATP III At-A-Glance: Quick Desk Reference.(22)

Treatment

Make lifestyle changes: The first step in improving your blood cholesterol levels is to make lifestyle changes:
  • Substitute good fats for bad fats in your diet 
  • Maintain a healthy weight
  • Stop smoking, if you smoke
  • Exercise regularly:  Gradually work up to 30 to 60 minutes a day, most days of the week.  This can include walking, swimming, cycling, jogging, aerobic dances or any continuous activity that increases your heart rate safely. Before beginning any exercise program, ask your doctor what is right for you.

Maintain good control of high blood pressure and diabetes if present. These diseases are important risk factors of heart disease.  Iin general, for any cholesterol level, the more risk factors you have, the higher your risk of coronary artery disease (CAD).  The American Heart Association guidelines call for blood pressure and body mass index assessment at least every two years and cholesterol and glucose testing at least every five years beginning at age 20. Start modifying any cardiac risk factors at age 20.

Cholesterol-lowering medications may be necessary in some people if lifestyle changes aren't enough. Read about medications that can help.


References click here

Written by N Thompson ARNP in collaboration with R Timmons MD, Internal Medicine and M Thompson MD, Internal Medicine.  Last updated March 2009
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