LOWERING CHOLESTEROL LEVELS
 

It seems like Americans are increasingly obsessed with their cholesterol levels.

There is a good reason for this. It has been proven that high cholesterol levels are a significant contributor to heart disease. Lowering the cholesterol level has been scientifically proven to prevent heart disease and prolongs life.  This has been proven for men and women, young and old. Even people with established heart disease can slow the progression of their disease and prolong their life by lowering their cholesterol levels.

The benefit of lowering the cholesterol level is not something that takes a long time. Within six months of starting treatment for a high cholesterol level, the risk of heart disease is already reduced.

Lowering the serum cholesterol level achieves these benefits by slowing or preventing the growth of atherosclerotic plaques in the arteries. Some plaques may even get smaller with time. A lower cholesterol level also helps the arteries of the heart dilate during times of stress to provide additional blood flow to the heart muscle. Finally, some cholesterol lowering medications seem to stabilize the atherosclerotic plaque so that it does not rupture-the process that is responsible for heart attacks.

CHOLESTEROL-GOOD AND BAD

You may have heard that our bodies contain a good cholesterol (known as HDL-cholesterol) which we want to keep as high as possible and a bad cholesterol (known as LDL-cholesterol) which we want to keep as low as possible.  These terms refer to the different types of protein molecules the cholesterol gets attached to in our blood stream.  More about this later.

Cholesterol in food is not attached to any protein. All cholesterol in food should be considered bad cholesterol since it will become bad (LDL) cholesterol in our bodies.

The total cholesterol measured by blood tests is the sum of the bad and good cholesterols. Since most of the cholesterol in our bodies is the bad (LDL) cholesterol, we like to see the total cholesterol as low as possible, generally less than 200. Blood tests can also measure the exact amount of the good and bad cholesterol which is a more accurate way to assess a person's risk of developing heart disease.

The serum triglyceride level is a measure of the circulating fat in the bloodstream. People with elevated triglyceride levels often have other risk factors for vascular disease such as high blood pressure, diabetes, low HDL-cholesterol and overweight. Elevated triglyceride levels are thought to confer an increased risk of cardiovascular disease.

DIET, FAT AND CHOLESTEROL

As you would suspect, cholesterol in the food we eat contibutes to the high levels found in some people's blood.  Equally important is the fact that the liver can actually create cholesterol. In many people, high cholesterol levels are due to an overproduction of cholesterol by the liver and not from eating too much cholesterol. The overproduction by the liver is usually on a genetic basis.

Fat in the diet also affects the cholesterol level. There are four different types of fats in our diet: Saturated fats, monounsaturated fats, polyunsaturated fats and a fourth type which goes by several names including trans fats, hydrogenated fats and partially hydrogenated fats. Trans fats occur rarely in nature (froms ruminant, cud chewing animals) and are generally produced artificially from naturally occuring unsaturated fats. They are used to convert oils to a solid or semisolid state such as in tub marraine or vegetable shortening.

It is important to note that saturated fats and trans fatty acids in the diet cause the liver to make even more cholesterol. In fact, these fats in our diet may raise the cholesterol level in the blood even more than dietary cholesterol! People eating diets high in saturated and trans fats have been shown to have an increased risk of developing and dying from cardiovascular disease. This is why we must carefully watch the amount of saturated and trans fat, as well as cholesterol, in the diet.

Saturated fat is primarily found in full fat dairy products, fatty meats and tropical oils such as palm and coconut oil.

The unsaturated fats (monounsaturated and polyunsaturated) in the diet don't raise the cholesterol level and actually have some health benefits but they are still fattening. Polyunsaturated fats appear to have more of a cholesterol lowering effect and greater health benefits than the monounsaturated fats. Sources of these fats include fruits, vegetables, vegetable oils and nuts.

The nutrition labels on foods list the levels of cholesterol, total fat, saturated fat, monounsaturated fat and polyunsaturated fat. However, they don't yet list the amount of the trans fat. You must look in the ingredients section of the label for "hydrogenated" or "partially hydrogenated" fats, oils or vegetable shortening. Trans fats are generally found in margarine (especially stick margarine), vegetable shortening, baked foods, snack foods and fried foods.

Fish oil contains a special type of polyunsaturated fat called omega-3 fatty acids. It is especially high in fatty fish such as salmon, mackerel, herring, kipper, pilchard, sardine and trout. These fats are also found in flaxseed, flaxseed oil, canola oil, soybean oil and nuts. Omega 3 fatty acids lower triglyercide levels. They have a minimal effect on LDL (bad) cholesterol. Unfortunately, they also lower the HDL (good) cholesterol and contain fat calories.  They have a blood thinning effect which can help protect against heart disease but may increase bleeding risks.  They minimally lower blood pressure. They help stabilize the electrical conduction system of the heart. Some studies have shown that these fats do lower the risk dying from heart disease. Whether people should take omega 3 fatty acids supplements or just eat more of the aforementioned food products has not been determined.

Cholesterol attached to the LDL protein is what damages our blood vessels and significantly contributes to heart disease. Naturally, we want to keep the LDL (bad) cholesterol as low as possible. This is done by minimizing our dietary intake of cholesterol as well as the dietary intake of saturated and trans fats which cause the liver to manufacture even more cholesterol. Often, medications are needed as well.

Changing the diet alone generally results in an average decrease of 6 to 11% in the LDL cholesterol although there is a lot of individual variability. Some people will have much greater responses to diet whereas others may have almost no change at all. Very severe diets such as the Ornish diet or other strict vegetarian diets can result in a 40% lowering but it is very difficult for most people to stick with those diets.

The HDL protein takes cholesterol out of the lining of our blood vessels and protects against heart disease. So we like to keep the HDL (good) cholesterol as high as possible. This is accomplished by not smoking and by exercising.  Weight loss in overweight people will also help raise the HDL level. Some cholesterol medicines also help raise the HDL cholesterol. Post-menopausal hormones and alcohol in moderation also raises the good cholesterol.

Elevated triglyceride levels are treated by weight loss, caloric restriction, low fat diet, regular exercise, smoking cessation, avoidance of alcohol. If these measures are ineffective, certain cholesterol lowering medications can be used to lower the triglyceride level.

The American Heart Association recommends that no more than 200 milligrams of cholesterol be consumed per day (that's about the amount in one egg yolk). They recommend that 25% to 30% of the calories eaten should come from fat while other authorities allow as much as 35% of the total calories coming from fat. Higher fat intake increases the risk of heart disease. Fat intake less than 25% of the total calories probably doesn't have any further benefit and in fact, very low fat diets (such as 10% of total calories) may actually raise triglyceride (fat) levels and lower the level of good (HDL) cholesterol in the blood.

Saturated fat should account for less 7% of the total calories. Trans fat should be avoided as much as possible.  Polyunsaturated fat can account for up to 10% of total calories and monounsaturated fat up to 20%.

Carbohydrates should account for at least 50% - 60% of the total caloric intake with the remainder coming from protein. Something called the glycemic index measures how much a given carbohydrate containing food raises the sugar level in the blood. Foods with a high glycemic index raise the blood sugar more than food with a low glycemic index. High glycemic index foods have been associated with lower HDL cholesterol levels, higher triglyeride levels and more heart disease.

The Mediterranean diet refers to the typical diet of Mediterranean people such as those living in the southern European countries. This diet was studied in heart attack survivors. Compared to a typical diet, the Mediterranean diet led to a 50% to 70% lower risk of recurrent heart disease. This diet is consistent with the American Heart Association recommendations above as well as the specific dietary tips in the next section of this page.

The Mediterranean diet emphasizes fruits, vegetables, grains such as bread and cereal, potatoes, beans, nuts, seeds and fish. Eggs and red meat are avoided. Poultry is consumed in low to moderate amounts. Olive oil and canola oil are the preferentially used oils. Instead of butter, margarine with low saturated fat but containing extra fats known as linoleic and alpha-linolenic acids is used. Wine is allowed with meals in moderation.

PRACTICAL TIPS-WHAT TO EAT AND HOW TO COOK

How does one accomplish these goals? The answer is not simply to eliminate foods that you enjoy but rather, to substitute equally enjoyable, healthy alternatives as much as possible.

There is no cholesterol in fruit or vegetables. The main dietary sources of cholesterol and saturated fat include red meats, organ meats, and dairy products. The skin of chicken and turkey also has a lot. Dark meat has more than white meat. The tropical oils, coconut and palm, are very high in saturated fat. Hydrogenated fats are found in margarine (especially stick margarine), vegetable shortening, baked foods, fried foods and snack foods.

When a person eats meat it should be mostly fish and white meat chicken or turkey (without the skin). People who eat fish once or twice weekly definitely have less heart disease than those who don't. Don't obsess about which fishes are lowest in fat or cholesterol. That will just make it even more difficult to stick with and enjoy the diet. Any diet high in fish is associated with a decreased risk of heart disease. Shellfish has some cholesterol but is low in fat and is okay to eat. Shrimp has the highest cholesterol content of all the shellfish.

If red meat is eaten, it should be a lean cut. Examples include flank steak, sirloin tip, round steak, rump roast, veal chops, small loin lamb chops and lean ham. Processed meats such as bologna, bacon and frankfurters are very high in fat but low fat varieties are now becoming available. Organ meats such as liver and sweetbreads are high in cholesterol and should be eaten only rarely.

If dairy products are consumed, they should be the 1% low-fat or no fat variety. The cholesterol in eggs is all in the yolk. Eating egg whites is a good source of dietary protein. If you like the yellow color, cholesterol-free egg substitutes are available in the supermarket. A recent study showed that consumption of one egg a day does not contribute significantly to the development of heart disease. This may be due to antioxidant vitamins and unsaturated (rather than saturated) fats in eggs that counterbalance the deleterious effect of the cholesterol.

Try to use liquid margarine such as margarine made from rapeseed oil, soybean oil or olive oil in place of butter.  Substitute 1% or no fat milk for regular milk. Ditto for yogurt. Sherbet or low fat yogurt is preferable to ice cream.  Low fat cheeses can be identified as those containing less than 5 grams of fat per ounce. There are low fat varieties of cottage, American, Swiss, cheddar and Monterey cheeses. Ricotta, part-skim milk mozzarella and Jarlsburgh are other examples of low fat cheeses.

Margarine has less saturated fat than butter but may contain more hydrogenated (trans) fat. Stick margerine has very high amounts of hydrogenated fats and may be actually worse  for the cholesterol level than butter. The softer margarines that come in a tub or liquid form are better for the cholesterol level because they are lower in hydrogenated fat and saturated fat than stick margarine and butter. The best bet is to look for margarine made with unsaturated liquid vegetable oil. Soybean or olive oil are also safe substitutes.

Now there are available margarines and salad dressings that contain naturally occuring chemicals derived from plants called "sterols" and "stanols." These substances block the absorption of cholesterol by the intestines. The use of sterol-enriched products (such as Benecol and Take Control margarine) may lower the level of bad cholesterol in the body by 10% to 15%.

When cooking with oil, palm, cottonseed and coconut oils should be avoided in favor of  olive, corn, canola (rapeseed), sunflower and safflower oils. Avoid fried foods in restaurants unless you know what kind of oil they were cooked in.

Avoid commercially prepared and processed foods such as cakes, cookies, crackers and other snack foods made from saturated or hydrogenated fats. Chocolate, nuts and avocados are also high in fat (however, the fat in nuts and avcados is unsaturated fat). If you are not sure, read the nutrition label and ingredients.

Dietary fiber, especially soluble fiber, helps lower cholesterol. Soluble fiber is found in whole grains such as oat, and cereal; legumes such as beans, peas, and lentils; citrus fruits and psyllium containing cereals and laxatives.

In general, it is prudent to eat a diet high in fruits and vegetables. These types of diets are definitely associated with lower cholesterol levels and a reduced incidence of heart disease. In addition to containing fiber, they also contain antioxidant substances (see Antioxidants and the Heart) including polyphenols; vitamins A,C, and E; as well as phytoestrogens (isoflavones) which lower cholesterol and act as antioxidants.

Phytoestrogens are naturally occuring estrogens found in plants. They include isoflavones such as genistein, glycetein and daidzein. These are found in soy products such as soybeans, tofu and miso soup. They are also found in tea, cereals,  legumes, onions and broccoli and fruits such as apples, cranberries, and strawberries. Isoflavones also have a mild blood thinning effect in addition to antioxidant activity and lowering cholesterol and triglyceride levels.

Fruits and vegetables also contain sterols (sitosterol) and stanols (sitostanol) which block the absorption of dietary cholesterol from the intestine to help lower the cholesterol level.

Plant sulfur compounds are found in garlic, leeks and onions and may be responsible for the cholesterol lowering effect reported in some studies by garlic. The active component of garlic is allicin. Do note however that large doses of garlic can have serious side effects, including anemia and allergic reactions. The most recent studies published on garlic actually found that it had only a minimal effect, if any, on serum cholesterol levels.

Replacing animal sources of protein with vegetable sources helps avoid the cholesterol inherent in most meat products. Various combinations of vegetables, legumes (peas, beans and lentils), fruits, nuts (walnuts, almonds, pecans), seeds (sesame and sunflower) and grains (oat, rice, corn, wheat, barley, rye) represent as good a source of protein as red meat. (Note that nuts are high in fat and therefore are fattening but it is mostly unsaturated fat.) Soy protein has an additional cholesterol lowering effect and contains antioxidant flavenoids (isoflavones). Tofu is processed soy and contains lesser amounts of these two substances. Poultry and fish also supply protein and are lower in fat and cholesterol than red meat.

Beware: even vegetables can be unhealthy if fried in an oil high in saturated fat or dipped in a high fat spread.

Vegetarians should note that their diet contains no vitamin B12 and they should discuss taking supplemental B12 with their physician.

Complex carbohydrates (starch) have traditionally been considered   preferable to simple carbohydrates (sugar).  However, judging  the effect of carbohydrates on cholesterol levels may have to take into account the glycemic index rather than simply considering whether the carbohydrates are simple versus complex.

Remember that all carbohydrates have calories and if you ingest more calories than you burn off, you will gain weight and the triglyceride (fat) levels in the blood will increase.

Whole grain breads and cereals, rice, legumes such as peas and beans, as well as pasta and potatoes have traditionally been considered healthy carbohydrate sources and they decrease cardiovascular risk. These recommendations may have to be refined by taking into account the glycemic index of foods.

Healthy snacks include air-popped popcorn, graham crackers, melba toast, rye crisp, soda crackers, fat free pretzels, bread sticks, English muffins, cereals as well as fruits and vegetables.

Healthy desserts include fruit, ices, sherbet, angel food cake, jello, low fat yogurt and low fat ice milk.

Watch out for high fat and cholesterol gravy, sauces, salad dressings, spreads and toppings that can undo all the good of an otherwise healthy meal.

Low fat methods of food preparation include baking, broiling, microwaving, steaming, grilling, poaching and roasting. Breading and frying should be avoided. When frying is done, it should be done with the cooking oils listed above or in a nonstick pan. When roasting, first trim the fat and then place the meat on a rack so the fat can drip away. Soups and stews should be chilled for a few hours so that the congealed fat on top can be removed.

Substitute low fat and cholesterol ingredients for high fat and cholesterol ingredients. Use egg whites or substitutes instead of whole eggs. Use margarine or oil fortified with crackers instead of butter or hard shortening. Substitute cocoa for baking chocolate.

Tofu (soy) can take the place of eggs or dairy products in many recipes. Soy flour and isolated soy protein can be added tp kaked foods to improve their nutritional quality without affecting their taste. Texturized vegetable protein made from soy can be used as a meat extender or replacement.

Be extra careful when eating in a restaurant or eating a hurried meal. These are the situations where we tend to fall off the wagon.

Alcohol in moderation seems to prevent heart disease. This may be due to the fact that it raises the level of good cholesterol in our blood and has antioxidant and blood thinning effects. Substances in grapes and red wine called phytoestrogens (isoflavones) such as resveratrol are probably responsible for these effects. Polyphenols are also an antioxidant substance found in red wine.

Coffee may raise cholesterol levels, particularly if the coffee is boiled directly in the water. Filtered coffee may have less of an effect on cholesterol. Coffee from Arabica beans will have less of an effect on cholesterol than coffee from Robusta beans. It is probably not the caffeine but other substances in the coffee that cause it to raise cholesterol levels.

The goal of dietary modification is not to eliminate favorite foods but to replace them with satisfying alternatives. It is recognized that no one will stick with a diet they don't enjoy. Meeting with a dietician can be very helpful in planning an enjoyable and healthy diet and well worth the small, nominal charge. It is also important to note that no food is totally given up forever. A high cholesterol meal, once in a great while, such as on a special occasion will do no harm. Moderation and common sense are all that are required.

OTHER DIETARY RESOURCES

The International Task Force for Prevention of Coronay Heart Disease has a comprehensive table of dietary recommendations that is quite helpful.

The American Heart Association has a number of cookbooks for enjoyable, healthy food.

Also recommended is The Stanford University Healthy Heart Cookbook and Life Plan by Helen Cassidy Page, John Speer Schroeder, M.D., and Tara Coghlin Dickson, M.S., R.D. published by Chronicle Books, San Francisco, CA, 1996.

Another excellent book is Good Fat, Bad Fat by Glen Griffin, M.D. and William Castelli, M.D. published by Fisher Books, Yucson, AZ, 1997

Other helpful websites include Eating to Lower Your High Blood Cholesterol from the National Institutes of Health and the Food and Nutrition Center from the Mayo Clinic.

SPIN (Special Program in Nutrition) developed by Ann H. Snyder, R.D., Lucy B. Adams, M.S. and Thomas P. Bersot, M.D., PhD. of the Gladstone Institute of Cardiovascular Disease is a curriculum for a heart healthy diet designed to be taught to third and fourth graders as well as their parents. It served as a source for some information on this web page. Their web page gives instructions on how you can obtain their excellent cookbook and curriculum.

The definitive book on the nutritional values of almost any food you can think of is Bowes & Church's Food Values of Portions Commonly Used, 17th edition by Jean A.T. Pennington Ph.D., R.D. published by Lippincott Williams & Wilkins Publishers, Philadelphia 1997.

CHOLESTEROL LOWERING MEDICATIONS

As we stated above, in many people a high level of bad (LDL) cholesterol is on a genetic basis. Their bodies simply produce too much cholesterol, even if they eat a perfect diet. In these people, cholesterol lowering medications should be considered. There is no convincing evidence that cholesterol lowering medications cause cancer or death from reasons other than heart disease. Cancer causes the low cholesterol level, not vice versa.

There are three groups of cholesterol lowering medications presently available by prescription:  resins, fibrates, and statins.  Another compound that is effective in lowering cholesterol is not a drug at all but a vitamin, Niacin or  Vitamin B3, and has the added benefit of raising HDL, the good cholesterol.

RESINS

These medications bind bile that was secreted into the intestine and prevent it from being reabsorbed. The liver makes bile out of cholesterol. Since these medications cause the body to lose bile, the liver then takes cholesterol out of the blood stream and converts it to bile, thus lowering the serum cholesterol level. These medications primarily lower the LDL-cholesterol level but not the triglyceride level. The major side effects are gastrointestinal, especially constipation.

The taste of the powders can be a problem. It is best to mix them in a noncarbonated beverage, soup or applesauce. The starting dose should be low and then slowly increased to avoid side effects. Taking them with meals also helps avoid side effects. If constipation occurs, increasing dietary fiber or taking metamucil may help.

These medications can prevent the absorption of other medications. Thus, other medications should either be taken one hour before or 4 to 6 hours after taking a bile acid sequestrant.

FIBRATES

These medications lower LDL-cholesterol and triglycerides as well as raise HDL-cholesterol levels. They do this by inhibiting the production of proteins containing fat and cholesterol by the liver and the release of trigycerides from fat stores in the body. There are no special instructions for taking these medications. Clofibrate is rarely used nowadays.

STATINS

These are the cholesterol lowering medications that have been getting a lot press lately. They have the strongest evidence (compared to the other classes of cholesterol lowering medications) that they reduce the future risk of cardiac events and death.

They work by inhibiting an enzyme in the liver that is responsible for manufacturing cholesterol. They primarily lower LDL-cholesterol but also raise HDL-cholesterol levels and sometimes, lower triglyceride levels as well. They differ from one another in terms of their potency. If a low potency statin (fluvaststatin, pravastatin) is lowering the cholesterol level adequately, there is probably no need to change to a higher potency statin (atorvastatin, simvastatin, cerivastatin). Atorvastatin and cerivastatin appear to be the best at lowering triglyceride levels.

Statins have other effects that also help prevent heart disease. These include a mild blood thinning effect and an antiinflammatory effect on the walls of the blood vessels.

The main side effect to be alert for is muscle aches and pains. These should be reported to the physician immediately. Blood tests are also monitored periodically for liver dysfunction. This complication is infrequent, readily reversable and rarely serious.

The liver makes cholesterol mostly at night. Therefore, it is recommended that these medications be taken in the evening.

The choice of cholesterol lowering medication must be made by a licensed physician. Niacin is a very effective cholesterol lowering medication that is available over the counter but (like all other medicines), it can have significant and serious side effects. It should only be used under a physician's supervision. There are now many well tolerated and safe medications to lower cholesterol levels that your physician can prescribe if needed.

NIACIN

Niacin (nicotinic acid) lowers LDL-cholesterol and triglycerides and also raises HDL-cholesterol. It accomplishes this by inhibiting the production of fat and cholesterol containing proteins by the liver.

The most common side effects of the short acting, three times a day niacins are flushing, itching and dizziness. These can be minimized by taking the following steps:

Take it with food or a cold beverage-avoid hot beverages.

One aspirin a day helps decrease these side effects. Check with your doctor before taking aspirin

Start at a low dose and slowly work your way up to the target dose.

Note: Niacinamide (nicotinamide) is not niacin and has no effect on cholesterol.

The following studies can be accessed at:  http://qualitycounts.com/fphdl.html

Question regarding a new cholesterol-lowering supplement, Policosanol - Life Extension Magazine, 11/01 - "Studies show that niacin (B3) in doses of 1.5 grams to 3 grams lower triglycerides levels and raise HDL concentrations. Those who tolerated higher doses of niacin (nicotinic acid) showed even more improvement in lipid levels. Some people taking just 1000 mg of flush-free niacin see an elevation in beneficial HDL. Green tea also has been shown to elevate levels of HDL while lowering serum triglyceride levels. In the Journal of Molecular Cell Biochemistry, curcumin has been demonstrated, in vivo, to decrease triglycerides and increase HDL. In a study published in 1989 by the Journal of Associated Physicians-India, 125 patients receiving gugulipid showed a drop of 16.8% in triglycerides, and a 60%  increase in HDL cholesterol within three to four weeks. Make sure you are taking at least six Mega EPA fish oil capsules daily, as low dose fish oil may not adequately suppress triglycerides. Finally, there are some lifestyle changes you may wish to consider. If you are overweight, weight loss would be recommended, as it would help to lower triglycerides and raise HDL. Also, try reducing carbohydrates, which can raise triglycerides".

Product Review: Omega-3 Fatty Acids (EPA and DHA) from Fish/Marine Oils - ConsumerLabs.com, 11/20/01 - "It's been discovered that EPA and DHA may help prevent heart disease and atherosclerosis by lowering triglyceride levels, raising HDL ("good") cholesterol and, possibly "thinning" the blood ... By decreasing inflammation, EPA and DHA can also reduce the pain of rheumatoid arthritis ... Fish oils may also be useful in treating a host of conditions including bipolar (manic-depressive) disorder, Raynaud's phenomenon (abnormal sensitivity of hands and feet to cold), lupus, IgA nephropathy, kidney stones, chronic fatigue syndrome, Crohn's disease, cystic fibrosis, and ulcerative colitis ... EPA specifically may be helpful for schizophrenia, while DHA may be more helpful in reducing high blood pressure ... DHA may be helpful in the treatment of disorders such as attention deficit disorders, dyslexia, and cognitive impairment and dementia ... experts now believe that the American diet contains too little omega-3 fatty acids and too much omega-6 fatty acids".

Cardiovascular Health - Nutrition Science News, 9/01 - "HDL cholesterol was significantly increased in the intervention [coenzyme Q10] group without affecting total cholesterol or LDL cholesterol"

A Fish Story - Nutrition Science News, 4/01 - "daily consumption of very low daily doses of EPA/DHA (120 mg/180 mg, about one standard fish oil capsule) in an enriched milk led to a 19 percent decrease in blood triglycerides and a 19 percent increase in HDL cholesterol after six weeks ... It is unclear whether EPA is superior to DHA, although EPA has proven more potent in relaxing cow coronary arteries and producing the vasodilator gas, nitric oxide, in vitro"

by Anthony Almada
(Anthony Almada is a nutritional and exercise biochemist and has collaborated on more than 50 university-based clinical trials. He is the co-founder of EAS and founder and chief scientific officer of IMAGINutrition.)

The omega-3 fatty acids eicosapentaenoic acid (EPA) and decosahexaenoic acid (DHA), and their primary carrier in the diet, fish,
have been the subjects of thousands of studies. In most of these studies, researchers have examined the influence of fatty acids on blood clotting, cancer, fat metabolism, or inflammation, as well as their effect on antioxidants.1-4 A recent study involving almost 80,000 nurses during a 15-year period revealed that a half serving of fish or 500 mg of omega-3 fats daily provided greater protection against certain types of strokes than aspirin.5 This finding comes on the heels of an FDA ruling permitting a "qualified" health claim for omega-3 fatty acids. The claim ruling was based on evidence that a protective benefit against heart disease is "suggestive, but not conclusive."

One recent open-label study of eight people (men and women) has shown that daily consumption of very low daily doses of EPA/DHA (120 mg/180 mg, about one standard fish oil capsule) in an enriched milk led to a 19 percent decrease in blood triglycerides and a 19 percent increase in HDL cholesterol after six weeks.6 It is unclear whether EPA is superior to DHA, although EPA has proven more potent in relaxing cow coronary arteries and producing the vasodilator gas, nitric oxide, in vitro.7 Expect to see more omega-3s, especially EPA, on the market.

REFERENCES

    1. Shimokawa H. N-3 fatty acids in vascular function: beneficial effects of eicosapentaenoic acid on endothelial
        vasodilator function in animals and humans. World Rev Nutr Diet 2001;88:100-8.

    2. Babcock T, et al. Eicosapentaenoic acid (EPA): an anti-inflammatory n-3 fat with potential clinical applications.
        Nutrition 2000;16:1116-8.

    3. Stalenhoef AFH, et al. The effect of concentrated n-3 fatty acids versus gemfibrozil on plasma lipoproteins, low
        density lipoprotein heterogeneity and oxidizability in patients with hypertriglyceridemia. Atherosclerosis 2000;153:129-38.

    4. Noguchi M, et al. The role of fatty acids and eicosanoid synthesis inhibitors in breast carcinoma. Oncology 1995;52:265-71.

    5. Iso H, et al. Intake of fish and omega-3 fatty acids and risk of stroke in women. JAMA 2001;285:304-12.

    6. Visioli F, et al. Very low intakes of n-3 fatty acids incorporated into bovine milk reduce plasma triacylglycerol and
        increase HDL-cholesterol concentrations in healthy subjects. Pharmacol Res 2000;41:571-6.

    7. Omura M, et al. Eicosapentaenoic acid (EPA) induces Ca2+-independent activation and translocation of endothelial
        nitric oxide synthase and endothelium-dependent vasorelaxation. FEBS Lett 2001;487:361-6.

Niacin Reduces Triglycerides, Increases Good Cholesterol In Diabetics - Doctor's Guide, 3/20/01

ORLANDO, FL -- March 20, 2001 -- Diabetic patients who take a daily, slow-release form of niacin (Niaspan) appear to increase their
levels of high-density lipoprotein cholesterol and reduce blood triglycerides.

The drug regimen, however, does not affect control of blood sugars, researchers reported here yesterday (March 19) at the 50th Annual Scientific Session of the American College of Cardiology (ACC).

"There had been concern that niacin use in diabetic patients might increase blood sugar levels," said Gloria Vega, Ph.D., professor of clinical nutrition at the University of Texas Southwestern Medical Center in Dallas, Texas, "but we didn’t see that in our study."

Dr. Vega and her colleagues, including Scott Grundy, MD, director of University of Texas Southwestern’s Center of Human Nutrition,
enrolled 148 patients in the 16-week study of how extended-release niacin would affect blood lipids in Type 2 diabetic mellitus patients.  Patients were randomised to receive placebo, 1,000 mg of niacin or 1,500 mg of prescription niacin.

Patients taking the active agent increased high-density lipoprotein (HDL) cholesterol by 20 to 24 percent compared with a 4 percent
 increase among the placebo patients. At the same time, triglycerides were reduced 15 to 29 percent in the patients on niacin
 compared with a 5 percent reduction among patients taking placebo.

"This study convincingly demonstrates that not only is extended-release niacin a relatively safe drug for use in patients with diabetes at these doses, but such patients who have lower than average HDL levels should be considered candidates for this treatment," Dr. Vega said.

She said that there were no significant differences in key markers of glucose control-hemoglobin levels and fasting glucose levels. About half of the patients in the study were taking statin drugs-mainly atorvastatin, pravastatin and simvastatin-to control cholesterol
 levels, Dr. Vega said.

"Niacin is known to enhance the LDL [low-density lipoprotein]-lowering effect of statins," said Adolph Hutter, MD, professor of medicine at Harvard Medical School/Massachusetts General Hospital in Boston, Massachusetts. "Adding niacin to the drug regimen of diabetes patients to increase HDL-cholesterol levels appears to make sense. The longer-acting form of niacin used in the study has fewer side effects-particularly flushing-than other niacin formulations."

"This study showed that low doses of niacin are an effective treatment in positively altering the lipid risk profile for patients with
 diabetes who have dyslipidemia, including those already on a statin, and that individuals with the disease who have lower than average HDL levels should be closely monitored and treated to help reduce their risk of heart disease," said Dr. Grundy, a co-author of the report presented at the ACC.

Although there are over-the-counter formulations of niacin on the market, Dr. Vega said patients should not take the medications
 without consulting their physician.

Soy Beneficial Even for Individuals With Normal Cholesterol Levels - Medscape, 3/6/01, user=benhess, pwd=asdfgh - "Even people with normal cholesterol levels can benefit from eating more soy because it boosts levels of high-density lipoprotein cholesterol"

Effects of policosanol in older patients with type II hypercholesterolemia and high coronary risk - J Gerontol A Biol Sci Med Sci 2001 Mar;56(3):M186-92 - "while significantly (p é .01) incrrrreasing (p < .001) high-density lipoprotein cholesterol (HDL-C) by 14.6% and 29.1%, respectively ... No serious adverse experiences occurred in policosanol patients (p < .01), compared with seven adverse experiences (7.9%) reported by placebo patients"

Niaspan (Niacin Extended Release Tablets) Safe And Effective For Diabetics - Doctor's Guide, 11/14/00

Can Eating Soy Help Save Lives? - ABC News, 11/13/00

Statin Plus Niacin Reduces Heart Attack Risk, Reverses Arterial Build-up - Doctor's Guide, 11/13/00

NEW ORLEANS, LA -- November 13, 2000 -- Treatment with a combination of statin and niacin can slash the risk of hospitalization for chest pain or a heart attack by 70 percent among patients who are likely to suffer heart attacks and/or death from cardiovascular problems,  according to a study presented here by researchers at the University of Washington School of Medicine.

The treatment combines two already well-known ways of improving cardiac health: the use of a statin drug to lower levels of the "bad"
cholesterol, LDL, and the use of niacin to boost levels of the "good" cholesterol, HDL. The study found that use of this combined treatment, in people with low levels of good cholesterol and average levels of bad cholesterol, could even remove plaque buildup in the arteries. Cardiovascular disease is the No. 1 killer in the Western Hemisphere.

 At the start of the study and again after three years of treatment, doctors took angiograms of the patients' arteries. The angiograms showed that in most of the patients who received the combination treatment, plaque buildup had actually decreased.

"This is the first demonstration of a striking clinical benefit from combination drug therapy for a common type of coronary disease
patient," said Dr. B. Greg Brown, a cardiologist and UW professor of medicine.

Researchers are finishing up their analysis of the study data, and plan to submit their report this winter for publication. Dr. Brown is the study's lead author. The results were presented in New Orleans on Nov. 13 at the Scientific Sessions of the American Heart Association.

"This interesting study is a good demonstration of the enormous value of cholesterol management in patients with coronary disease," said Dr. Claude Lenfant, director of the National Heart, Lung, and Blood Institute, which funded the study.

The same study found that a mixture of antioxidant vitamins had no effect on cardiovascular outcomes. Scientists are not sure why this is so, since there has been laboratory evidence that suggests antioxidants should be helpful.

"More research and larger studies are needed to confirm the lack of effectiveness of antioxidant vitamins on risk for coronary events," Dr. Lenfant said.

Dr. Brown was involved in the first studies in the late 1980s that showed that a kind of statin, lovastatin, could reduce the occurrence of major cardiovascular events by about 25 to 35 percent. Giving statins to people with cardiovascular disease is now common.

"What you expect with statins is a slowing of the disease progression, but not a stopping. Arteries continue to get narrower, but not as fast," Dr. Brown said. "But when niacin is combined with a statin, the artery blocking actually improves, on average."

Dr. Brown and colleagues surmised that combining simvastatin with niacin might prevent even more heart attacks and such cardiac events.  The goal would be to reduce plaque buildup. That's important because the cholesterol-rich plaque is what can clog artery walls and lead to fatal complications.

The statin lowers blood levels of LDL, which is called the "bad" cholesterol because it is more likely to clog arteries. Niacin, or Vitamin B3, is the best agent known to raise blood levels of HDL, which helps dissolve cholesterol deposits from the artery walls.
The 160 patients involved in the study had low levels of good HDL cholesterol (a level of 35 or less). At least four out of every 10 people with coronary artery disease fit this profile. But the study results may have implications for other people with coronary diseases. They would have even higher levels of HDL - and having higher levels of the good cholesterol should only help them, Dr. Brown said.  Some patients in this study received simvastatin and niacin, while others received antioxidants. A third group received three treatments while a fourth, control, group received placebos. All patients received exercise training and dietary counseling.

The results for those receiving statin and niacin were startlingly different than the others. The average level of HDL increased from 31 to 38, while the average LDL dropped from 125 to 76 -- that is considered an extremely good level of the bad cholesterol. Angiograms showed that most of these people had no additional plaque buildup over the years. In many of them, the amount of plaque actually decreased.

"What we saw was a reversal of the disease," Dr. Brown said. "The patients' arteries, on average, had stopped narrowing and begun to improve."

The study involved use of niacin at moderately high and carefully supervised levels. Dr. Brown said that people should only take niacin under a doctor's supervision, because in some patients, the doctor may wish to monitor the patient's liver. Rarely, the unsupervised use of niacin can cause severe liver problems, including liver failure.

The study had included antioxidants because there has been considerable evidence that they should help protect against the basic
mechanisms for cholesterol buildup. The antioxidants involved in this study include Vitamins C, E, beta carotene and selenium.

Orange Juice Improves Hypercholesterolemic Blood Lipids - Doctor's Guide, 11/9/00

Drinking 750 mL of orange juice daily improves lipid profiles in patients with hypercholesterolemia.

Previous research has indicated that orange juice, a rich source of vitamin C, folate and flavonoids, induces hypercholesterolemic responses in animals.Canadian researchers wanted to know whether it beneficially altered blood lipids in people with moderate hypercholesterolemia.

They studied 25 healthy men and women with elevated plasma total and low-density lipoprotein (LDL) cholesterol and normal triacylglycerol concentrations.

Participants incorporated three different doses of orange juice sequentially into their diets. They added 250 mL, 500 mL or 750 mL (one, two or three cups) of the juice, each dose over a four-week period. A five-week washout period followed.

Their plasma lipid, folate homocysteine and vitamin C concentrations were measured at baseline, after each treatment and after the washout period.

Researchers report that daily consumption of 750 mL of orange juice increased high-density lipoprotein (HDL) cholesterol concentrations by 21 percent, triacylglycerol concentrations by 30 percent and folate concentrations by 18 percent.

It decreased participants' LDL-HDL cholesterol ratio by 16 percent. It did not affect their homocysteine concentrations.

These results were not found with either the 250 mL or 500 mL daily dosages of orange juice.

Study findings confirm the value of nutritional recommendations that people consume from five to 10 servings of fruit and vegetables each day, the researchers comment.

American Journal of Clinical Nutrition, 2000; 72: 1095-1100.

Spent Yeast Improves Cholesterol Count - Nutrition Science News, 5/00

Beta-glucan, the much-studied fiber that lowers cholesterol and earned an FDA health claim for oat products, is also abundant in spent yeast from breweries and bakeries. According to the first study on yeast-derived beta-glucan, the easily dissolved fiber not
only lowers low-density lipoprotein (LDL) and total cholesterol, it raises high-density lipoprotein (HDL) levels as well. The combination of low LDL and high HDL levels decreases the risk of coronary artery disease.

The study by Robert Nicolosi of the Center for Cardiovascular Disease Control at the University of Massachusetts in Lowell and Stacey Bell of Medical Foods Inc., Cambridge, Mass., included 15 obese men ages 20 to 60 with high cholesterol (greater than 240 mg/dL). After their baseline blood samples were taken, all the men supplemented with 7.5 g of beta-glucan fiber dissolved in orange juice twice daily for eight weeks. Blood samples were repeated at weeks seven and eight of fiber consumption and again at week 12.

During the 12-week study, the men's HDL increased significantly, by 16 percent, while total cholesterol and LDL cholesterol declined. The authors note that when combined with a special diet, beta-glucan supplementation may in some cases eliminate the need for cholesterol-lowering drugs.

Labels for oat foods containing 0.75 g or more of beta-glucan per serving may claim the food reduces cholesterol; however, oat fiber by itself does not raise HDL concentrations. The study was partially funded by a company that produces beta-glucan fiber.

Orange juice puts squeeze on disease - USA Today, 11/11/99 Orange Juice Raises "Good" Cholesterol - Intelihealth, 11/10/99 - "Dr. Elzbieta M. Kurowska told Reuters Health that once the subjects were drinking three glasses of orange juice a day, their HDL levels increased 21% and the LDL/HDL ratio dropped 16%. . . .  Kurowska attributes the effects of orange juice on cholesterol to the flavonoid hesperidin found in oranges."

Drinking three glasses of orange juice a day increases high density cholesterol (HDL), the so-called "good" cholesterol, and lowers the ratio between HDL and low density cholesterol (LDL) — the "bad" cholesterol, according to a study presented at an American Heart Association meeting.

A team at the University of Western Ontario, London, Canada, asked 16 men and 9 women with high blood cholesterol levels (ranging from 213 to 325 mg/dL) to drink one glass of orange juice a day for 4 weeks, then two glasses a day for 4 weeks, and then three glasses a day for 4 weeks. This was followed by a 5-week washout period, during which subjects were not asked to drink juice.

Dr. Elzbieta M. Kurowska told Reuters Health that once the subjects were drinking three glasses of orange juice a day, their HDL levels increased 21% and the LDL/HDL ratio dropped 16%. Orange juice also resulted in an increase in folate levels, which are known to cause a drop in homocysteine levels. Cardiologists are finding that high homocysteine levels appear to be a risk factor for heart disease.

"The (cholesterol) effect was still there after the washout period," Kurowska said. While vitamin C levels dropped back down after the end of the study, the improvements in cholesterol persisted, she said.  "Maybe these (orange juice) compounds have a prolonged effect," she said.

The researcher added that none of the subjects reported weight gain, "even though this was a considerable increase in sugar (intake)... The subjects compensated by changing their diets in other ways."

Kurowska attributes the effects of orange juice on cholesterol to the flavenoid hesperidin found in oranges. She would next like to study the effects of grapefruit juice on cholesterol. "The primary flavenoids in grapefruit juice are different from those in orange juice," the Canadian researcher noted.

High Levels of HDL Cholesterol Can Save Your Life - ABC News, 11/3/00 - "So how much HDL is enough? Current guidelines say 35 milligrams per deciliter of blood (mg/dl) is normal, but most cardiologists would prefer you to have an HDL count that’s twice that. “The higher the better,” says Gaziano. “Once you get over 60 mg/dl, it’s a strong positive factor in avoiding heart disease.” ... this will
increase your HDL by 21 percent (or 10 to 20 points) within 4 weeks. “We’re not sure, but this effect may be due to a flavonoid in orange juice called hesperidin"

Rimostil May Increase Bone Density While Raising Good Cholesterol - Doctor's Guide, 9/27/99 - "The second effect was on HDL cholesterol levels. Falling HDL levels after menopause is one of the main reasons that older women suffer heart disease and stroke. P-081 caused an average 28% rise in HDL levels, essentially restoring their HDL levels to pre-menopausal levels" - see Rimostil at iHerb (5% discount code "qc")

The Body's Balancing Act - Health & Nutrition Breakthroughs, 1/99
(by Bill Sardi of San Dimas, Calif., is a health journalist, consumer advocate and health industry consultant (billsardi.com).

Does high cholesterol really reflect bad health? Perhaps it's high time to take another look.

The prevalent wisdom that a low-fat diet and cholesterol reduction are essential to good cardiovascular health is coming under increasing scrutiny. An examination of the foundations of this view suggests that in many aspects it was ill conceived from the outset, and with the accumulation of new evidence it is progressively becoming less tenable." --Social Science Medicine 1994;39:433-47

In the past decade, Americans have dramatically increased their cholesterol awareness. It is a widely held belief that a low-fat, low-cholesterol diet produces low circulating blood levels of cholesterol; and that lower cholesterol levels, in turn, reduce the risk of heart disease and atherosclerosis, thereby lengthening life span. But in fact, scientific research doesn't necessarily confirm these assumptions.

Cholesterol is a waxlike fatty substance produced in the liver. Cholesterol particles are lipoproteins--combinations of fats and proteins that travel in the blood and are essential for life. A cholesterol buildup on blood vessel walls is a known risk factor for coronary heart disease. Circulating levels of cholesterol are measured by its concentration in blood and expressed in milligrams per deciliter of blood serum (mg/dL).

High-density lipoprotein (HDL) cholesterol, known as "good" or "reverse" cholesterol, carries cholesterol out of arterial walls. The prevailing opinion is that HDL levels should be 35 mg/dL minimum and preferably exceed 60 mg/dL.

Low-density lipoprotein (LDL) cholesterol, known as "bad" cholesterol, carries cholesterol into arterial walls. Doctors like to keep LDL cholesterol levels below 130 mg/dL. But findings imply the ratio of LDL to HDL is really what matters. Scientific evidence suggests LDL levels should not exceed HDL levels by more than four to five times. So if HDL levels are 60 mg/dL and LDL levels are 180 mg/dL, or three times greater than HDL, cholesterol is within the acceptable range. However, if LDL cholesterol is 180 mg/dL and HDL is 30 mg/dL, a ratio of 6-to-1 LDL to HDL, then there is cause for concern.

Triglycerides are another circulating blood fat. Recent studies suggest triglyceride levels should not exceed 100 mg/dL.

Total cholesterol is a broad measure including all the fractions of circulating blood fats. The prevailing opinion is that total cholesterol levels less than 200 mg/dL are desirable.

Cholesterol and Mental Health

What often goes unreported are the potential harmful effects that can result from a reduction of dietary cholesterol and fat. A study of 140 elderly subjects showed that the risk of clinical depression increased threefold with very low total cholesterol levels (less than 160 mg/dL).1 In another study, six men were referred to a clinic for cholesterol reduction; four experienced measurable increases in
clinical depression.2 Along these lines, low or declining cholesterol profiles--that is, levels below a concentration of 4.78 micromoles per liter concentration in blood serum vs. 4.78 to 6.21 micromoles per liter (mm/L)--are associated with 3.16 times the risk of suicide among working-age men.3

One possible reason is that attempts to reduce cholesterol usually revolve around dietary fat reduction, which may create a whole new set of problems. One study involving 20 healthy young adults who switched from a typical American 40 percent fat diet to a 25 percent fat diet resulted in depressive mood changes in just one month.4 Efforts to reduce dietary fat often result in low consumption of essential fats, in particular the omega-3 fatty acids required for nervous system maintenance. This may explain the mood changes involved with cholesterol reduction.

Low Cholesterol and Mortality

Lowered total cholesterol can result in health problems more serious than mood  changes. Very low plasma total cholesterol, less than 160 mg/dL, has been shown to increase the risk of mortality from lung cancer by 1.75 times and 3.29 times among men and women, respectively.5 In a study of 595 coronary heart disease patients, noncardiac death, particularly from cancer, was 2.27 times higher among individuals with cholesterol levels less than 160 mg/dL. In fact, low total cholesterol is associated with high total mortality in patients with coronary heart disease.6 These adverse effects are believed to be related to cholesterol's role in  the delivery of antioxidants throughout the body.

Because cholesterol, primarily LDL cholesterol, is the carrier of fat-soluble antioxidants--such as vitamin E (alpha- and gamma-tocopherol) and carotenoid pigments such as beta-carotene, lutein and lycopene--any reduction in cholesterol results in reduced delivery of these antioxidants to tissues. It appears wise, then, to increase consumption of antioxidants when attempting to reduce cholesterol.

Cholesterol reduction seems even less prudent for older adults. Declining total cholesterol levels in nursing-home patients--losses greater than 45 mg/dL per year--increase the odds of mortality by more than six times.7 However ironic, it seems that high total cholesterol or low HDL cholesterol have not been important risk factors for mortality from coronary heart disease or any other causes among  people older than 70.8 Based on this information, there is no reason to believe cholesterol is a risk factor in patients older than 75, and cholesterol testing should be abandoned.9

Lowering cholesterol levels may reduce the risk of coronary heart disease, but do individuals then live longer? Researchers from the University of Arkansas in Little Rock performed a Medline search encompassing research published between 1966 and 1995. They found that reduced circulating blood cholesterol levels drop the coronary heart disease incidence but do not necessarily decrease mortality rates. Unfortunately, lowering cholesterol also appears to increase the risk for cancer, stroke and, oddly enough, coronary heart disease when certain medications are used. "The benefits may not outweigh the risks in all patients with elevated cholesterol," says researcher K.L. Geurian of the Medline study.10

Despite this evidence, the National Cholesterol Education Program wants to put 30 percent of Americans on cholesterol-lowering dietary and lifestyle programs and about 7 percent of the adult population on cholesterol-lowering drugs.11  Fortunately, most American physicians, apparently wary of the side effects caused  by anticholesterol drugs and other undesirable outcomes associated with  cholesterol reduction, are not likely to follow published guidelines for cholesterol control. One study shows that only 44 percent of primary care physicians would start a middle-age man with a total cholesterol of 276 mg/dL on cholesterol-lowering drugs.12

Raise HDL Instead

Blood vessel diseases such as atherosclerosis cannot be fully explained by cholesterol.  Blood vessel plaques visible on arteriograms do not correlate with plasma cholesterol levels.13  About half the U.S. adult population has total cholesterol levels less than 200, which is considered desirable. Yet it's a fact that as many heart attacks occur among people with total cholesterol levels less than 200 mg/dL as occur among individuals with total cholesterol greater than 300 mg/dL.  This prompted a 1992 National Institutes of Health (NIH) panel to suggest that low HDL levels may be responsible. The panel suggests HDL levels be kept above 35 mg/dL primarily by weight loss and smoking cessation.14  Blood plasma exposure to tobacco smoke causes depletion of circulating vitamin E, Co-Q10 and a variety of carotenoids--the very antioxidants that protect LDL cholesterol from oxidizing or hardening on blood vessel walls.15 About 5 to 10 percent of Americans have low HDL levels. Therefore, the focus should not be solely on lowering cholesterol but rather on raising HDL cholesterol. (See "Increasing the Good Cholesterol" below)

The NIH recommendation to emphasize HDL levels seems tardy given that it was known as early as 1985 that low HDL is the single strongest predictor of coronary heart disease.16  Researchers suggest HDL cholesterol is critical, particularly if the total cholesterol is less than 180 mg/dL. Total cholesterol is more predictive at levels greater than 250 mg/dL. Low HDL in the absence of elevated
LDL is correlated with an increased risk of coronary heart disease.17  When the level of LDL cholesterol exceeds that of HDL cholesterol by more than five times, this ratio is a better predictor of a heart attack than total cholesterol, LDL or HDL cholesterol alone.18 Furthermore, the risk for coronary heart disease is 2.5 times greater when HDL cholesterol levels fall below 35 mg/dL.

Other Contributing Factors

Current discussions regarding blood vessel disease now go beyond cholesterol and encompass other factors such as homocysteine, an undesirable blood protein that increases the risk of strokes and heart attacks. The antidote to homocysteine
buildup is folic acid, with vitamins B6 and B12 playing secondary roles. For the small group of individuals who are resistant to B-vitamin therapy, supplementary betaine may lower homocysteine by another metabolic pathway.20

Hydrogenated fats, also called trans fats, that raise LDL cholesterol are also considered risk factors for blood vessel disease. Oxidation, or hardening, of LDL cholesterol on blood vessel walls is also a recognized factor. Inside the lining of blood vessels, a type of white blood cell called a monocyte converts into a lipid-ingesting macrophage cell, which, along with smooth muscle cells,
accumulates lipids and becomes what is called a foam cell. As these lipid-laden cells accumulate inside blood vessel walls, they are visually observed as fatty streaks. Oxidized LDL cholesterol comprises most of the lipids attributed to these plaques. Using antioxidants such as vitamin E may, in fact, prevent this buildup.  Viruses, radiation or other inflammatory reactions may also hasten cholesterol plaque development.21 Selenium, bioflavonoids and carotenoids are also protection against cholesterol oxidation.22

Newly published data indicate that what once were considered normal triglyceride levels may increase coronary heart disease risk. Current guidelines published by the National Cholesterol Education Program call for triglyceride levels to be less than 200, but a research team from the University of Maryland in Baltimore now says the maximum triglyceride level should be half that amount. Triglyceride levels greater than 100 have been found to increase the risk for a new heart attack by 50 percent. Triglyceride levels can be reduced with exercise, low-saturated-fat diets, and foods and supplements rich in omega-3 fatty acids, such as flaxseed and fish oil.23

The Bottom Line

The current science on cholesterol suggests that low-fat diets may be counterproductive, plunging cholesterol levels may trade blood vessel disease for an array of mood and nervous disorders, and it is best to raise HDL "good" cholesterol--because elevating this blood fat doesn't just reduce the risk of a heart attack, it reduces mortality rates. That's the bottom line when it comes to
cholesterol control.

Increasing the Good Cholesterol
 Health & Nutrition Breakthrough, 1/99

So how can adults keep their good cholesterol (HDL) levels high? Natural approaches include diet, lifestyle and food supplements.

Low-fat diet: A recently published study suggests that, with regard to protection from heart disease, severe dietary fat restriction doesn't appear to offer much more benefit than moderate dietary fat reduction. Moderate dietary fat reduction produces optimal benefits. A moderate reduction in fat intake (from 36 to 28 percent of daily calories) has been found to produce maximum LDL reduction, but further fat restriction did not show any significant additional benefit. In fact, a very low-fat diet resulted in increased triglycerides and reduced HDL levels, both of which can indicate cardiovascular risk.1

Monosaturated oils: While low-fat diets may undesirably reduce HDL levels, incorporating olive and avocado oils into the diet significantly counteracts the HDL-lowering effect.2 This confirms the Mediterranean diet's benefits.

Dietary cholesterol: Despite efforts to warn consumers away from cholesterol-rich foods such as eggs, there is little evidence that dietary sources of cholesterol have any significant effect on circulating blood fats.3  As more cholesterol is consumed in the diet, the liver appears to down-regulate its synthesis of cholesterol. Young men who ate up to 14 eggs a week (one egg contains about 250 mg of cholesterol) did not experience a significant increase in cholesterol levels.4 Egg phobia appears to be unfounded.

Soy: Researchers performed a meta-analysis of 38 controlled clinical trials and determined that soy consumption significantly reduces total cholesterol, LDL and triglycerides but only slightly raises HDL.5 Still, the LDL reduction improved the LDL-to-HDL cholesterol ratio.2 Traditional fermented soy products such as miso and tempeh have been shown to contain greater concentrations of genistein, one isoflavone active ingredient, compared with soybeans, soy nuts, soy sprouts, tofu, soy flour or soy milk.6 However, soy isoflavones can lower plasma cholesterol by elevating thyroid hormone levels.  Regular soy users should be aware of its potentia gitroenic properties. At a concentration ranging from 1 to 10 micromoles in blood plasma, soy isoflavones may cause undesirable symptoms such as hair loss and fatigue, which are characteristic of thyroid disorders.7

Exercise, diet and weight loss: Not surprisingly, it's probable that the most natural and reliable way to elevate HDL cholesterol is through exercise and diet. In a small study of 32 people, exercise alone did not cause significant improvements in weight or cholesterol levels, but when subjects combined exercise with a low-saturated-fat diet, they were able to reduce total
cholesterol and triglycerides.8

In another study, 42 obese males followed the American Heart Association (AHA) diet and saw decreases in their total cholesterol, LDL cholesterol, triglyceride levels and HDL levels (HDL by 17 percent). When the AHA diet was accompanied by weight loss, there were additional drops in cholesterol profiles and, perhaps more importantly, a desirable 15 percent increase in HDL.9

A recent study of 180 postmenopausal women and 197 middle-aged men revealed that only when aerobic exercise was added to the daily regimen did a low-fat diet produce a significant drop in LDL cholesterol (14.5 mg/dL in women, 20.0 mg/dL in men).10

Antioxidants: An LDL cholesterol particle contains about 1,200 molecules of polyunsaturated fatty acids that are vulnerable to oxidation but are protected by about five to 14 molecules of fat-soluble antioxidants such as Co-Q10, vitamins C and E and carotenoids.11 Since LDL carries cholesterol into the arterial wall and HDL carries it out, oxidation of HDL interferes with this
reverse cholesterol transport. Fortunately, antioxidant vitamins protect against oxidation.12 So, for example, high plasma levels of vitamin C help maintain high HDL levels.13 Vitamin C also spares vitamin E from being oxidized in LDL cholesterol.14 Consequently, antioxidant combinations may be more beneficial than single supplements. A study of young adults shows that intake of vitamins A, C, E and beta-carotene from food supplements, along with other lifestyle modifications such as exercise and smoking cessation, is associated with higher HDL cholesterol levels.15 Furthermore, high circulating antioxidant levels may produce health benefits that cholesterol-lowering drugs have been unable to provide, such as reduced mortality. Although circulating levels of antioxidants in middle-aged men in 16 European countries were found to vary by a factor of six, the vitamin E levels accounted for 62 percent of the future mortality predictability.16

Garlic: A recent study examined the combined effect of garlic and omega-3 fatty acids on cholesterol. Garlic powder that provides 3,000-4,000 mcg allicin appeared to lower total cholesterol by about 9 to 12 percent, which is comparable to the effect of cholesterol-lowering drugs. Yet another recent and widely publicized study involving only 25 patients using 10 mg/day of garlic oil
did not confirm the previously reported cholesterol-lowering properties of garlic.17 However, this is not the first time garlic has failed to reduce circulating blood fats. Despite a few reports that garlic is ineffective at lowering cholesterol, an analysis of all published studies suggests that garlic is an effective cholesterol-lowering agent.18

In a notable study, 8,000 Germans with high cholesterol were placed on a low-fat diet and experienced a mild reduction in blood fats. But the addition of garlic to the diet reduced cholesterol four times more than diet alone.19 In another study, healthy volunteers were given fresh juice squeezed from 50 g of garlic just prior to eating 100 g of butter, and there was no increase in serum cholesterol.20

Garlic and omega-3: Omega-3 fatty acids are effective at lowering triglycerides; however, omega-3 can raise the LDL cholesterol count. But when the omega-3 fats are combined with garlic, the LDL increase vanishes.  So, when it comes to optimizing the LDL-to-HDL ratio, garlic and omega-3 fish oils appear to work better in tandem than they do independently.21

Niacin: Doses of 1,500 mg/day are effective at reducing total cholesterol, LDL cholesterol and triglycerides while increasing HDL. The main drawbacks of high doses of niacin are flushing, palpitations and worsening of diabetes, gout, hepatitis and peptic ulcers.22 Doses greater than 1,500 mg/day may also result in dry eyes, retinal swelling and loss of eyelashes and should therefore be avoided.23

Minerals: A magnesium deficiency increases LDL cholesterol buildup on blood vessel walls. However, oral magnesium supplementation in the range of 411-548 mg/day improves HDL levels.24 Low copper levels, which can be induced by taking more than 25 mg/day of zinc, may increase triglycerides as well as reduce HDL levels.25 Zinc/copper ratios should be monitored.*

Answers may lie in optimizing the LDL:HDL ratio - Nutrition Science News, 9/98

Prolonged treatment with slow release nicotinic acid in patients with type II hyperlipidemia - Medline, 11/97

Experts Urge Physicians and Patients To Look Beyond LDL Cholesterol - Doctor's Guide, 9/10/97

NEW YORK, NY -- September 10, 1997 -- Although physicians believe they have educated their patients thoroughly, patients still say they do not understand the basics about cholesterol and other lipid risk factors, according to surveys of patients with high cholesterol and of physicians who prescribe medications for high cholesterol. The two surveys, sponsored by Kos Pharmaceuticals, Inc., were released today.

Experts speaking at a Dyslipidemia Roundtable sponsored by the Citizens for Public Action on Blood Pressure and Cholesterol, Inc.,  re-emphasized that physicians' current primary emphasis on reducing total and LDL cholesterol is a critical starting point. However, for many patients, much more is needed.

The expert panel urged physicians to take the time and care to look beyond LDL at the other lipid levels that may factor into their patients' coronary heart disease (CHD) risk. Additionally, they urged patients to get more involved and proactively ask their physicians to explain the levels and the significance of all their lipoproteins in terms they understand.

Although more than half of physicians surveyed report their patients are knowledgeable about the components that comprise the total lipid profile, a majority of high-cholesterol patients said they are unfamiliar with these other lipids that are also indicators for coronary heart disease. In fact, almost half of patients surveyed said their physicians have never discussed with them all of the lipids that factor into total lipid management.

"These survey results clearly indicate that many patients who are at risk are either not receiving or not understanding critical cholesterol information, which could serve to motivate them to lower all of their CHD  risk factors," said Gerald Wilson, executive director for Citizens for Public Action on Blood Pressure and Cholesterol, Inc. "The patient survey, in fact, indicated that more than half of the patients surveyed did not know which lipoprotein was good (HDL) and which were bad."

Of the surveyed high-cholesterol patients, only nine percent knew their LDL level, 11 percent knew their HDL level and 12 percent knew their triglyceride level. Despite a majority of physicians saying they spend at least some time discussing HDL and triglycerides with their patients, only six percent of high-cholesterol patients say their doctor has discussed achieving ideal targets for HDL levels and only five percent have been told their triglyceride ideal target levels. Only three percent of the patients surveyed were familiar with Lp(a), an emerging lipid risk factor associated with CHD.

Maintaining low total cholesterol has traditionally been considered a significant step in decreasing individual risk for CHD. However, many people have multiple lipid disorders. New research highlights the importance of knowing the levels of all lipoproteins. In addition to low-density lipoproteins (LDL), high-density lipoproteins (HDL) and triglycerides each play a role in understanding a patient's global coronary risk. Further still, emerging risk factors including Lp(a) and abnormal LDL particle size (even when total LDL is normal) are the focus of ongoing research.

Coronary heart disease has been firmly linked to increased levels of LDL and decreasing elevated levels of LDL has conclusively been shown to reduce the incidence of heart attack and death. Made up of a family of cholesterol and triglyceride-rich particles, LDL levels when elevated or abnormal in composition can lead to hardening of the arteries and atherosclerosis. Conversely, low levels of HDL -- the body's good cholesterol -- may also increase an individual's risk for disease. The family of HDL particles carry cholesterol in the blood back to the liver, leading to its removal from the body.

Dr. Peter Kwiterovich, Director of the Lipid Research-Atherosclerosis Unit, Johns Hopkins University Hospital and a panelist for the roundtable discussion, highlighted the growing importance of knowing a patient's HDL levels in assessing the risk of CHD.

Recent studies illuminate the significance of lipoprotein abnormalities beyond LDL cholesterol in managing the risk of cardiovascular disease.  Citing research published in major medical journals, panelists discussed the link between elevated levels of both triglycerides and Lp(a), abnormal LDL particle size and the prevalence of heart disease. A study, for example, in the American Journal of Cardiology concluded high triglyceride levels were shown to more than double a person's risk for heart disease. According
 to a recent European study, women with elevated Lp(a) levels were almost three times as likely to suffer a heart attack.

"As we continue to learn more about HDL, triglycerides, and Lp(a), it is abundantly clear that measurement of total cholesterol is no longer enough to determine heart disease risk," said Antonio Gotto, MD, PhD, Stephen and Suzanne Weiss Dean and Professor of Medicine at Cornell University Medical College and roundtable speaker. "Awareness of LDL, HDL, and triglyceride levels is critical in assessing appropriate therapeutic options.  What works for one individual will not necessarily work for the next."

The survey involved 200 primary care physicians who prescribe medications for high cholesterol and 500 patients diagnosed with total cholesterol levels above 200.

A comparison of the efficacy and toxic effects of sustained- vs immediate-release niacin in hypercholesterolemic patients - Medline, 3/94 - "None of the patients taking IR niacin developed hepatotoxic effects, while 12 (52%) of the 23 patients taking SR niacin did"