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Cholesterol, High Cholesterol

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Introduction:

Preventive Health Advisor uses the equivalent terms hyperlipidemia, high or elevated cholesterol, dyslipidemia, lipid disorder, and hypercholesterolemia. High cholesterol is one of the major risk factors leading to heart disease, heart attack and stroke. Unfortunately, one in three Americans die of a cardiovascular disease. If you have other risk factors such as smoking, high blood pressure or diabetes, the risk from elevated cholesterol increases even further. Too much cholesterol in the blood can lead to cardiovascular disease. Cardiovascular disease is the No. 1 cause of death in the United States. Over 2,100 Americans die of cardiovascular disease each day, an average of one death every 40 seconds. Find out here how the most effective diet to lower cholesterol includes lowering trans-fat and saturated fat rather than simply eliminating cholesterol itself.

 

Hyperlipidemia is a diagnosis which refers to elevated blood lipids levels of total cholesterol, low density lipoprotein (LDL), and triglycerides. It also includes low levels of high density lipoprotein (HDL). At proper levels, lipids perform important functions in the body, but can cause health problems if they are at abnormal levels. Most hyperlipidemia is reversible by lifestyle habits or is treatable with both lifestyle habits and medications. Lifestyle contributors include obesity, lack of exercise, dietary habits, and smoking. Conditions that may cause hyperlipidemia include diabetes, thyroid disease, kidney disease, and pregnancy. Hyperlipidemia may also be inherited. Hyperlipidemia by itself does not cause any symptoms, but is a major risk factor for atherosclerosis and diseases such as coronary heart disease, stroke and peripheral vascular disease. Treatment of hyperlipidemia includes reducing excess weight, optimizing dietary changes, exercising, supplements, and medication. There are many Integrative Medicine and natural treatment options for prevention and improvement of hyperlipidemia. Preventive Health Advisor includes the best natural treatments available. As always, the primary care physician should oversee both natural methods and medication treatment used for high cholesterol until goals are met. Control of cholesterol is one of the most important goals described by American Heart Association (AHA) required to reduce the risk of cardiovascular disease, reduce risk of stroke and achieve ideal cardiovascular health.

Cholesterol is needed by the body to function and the majority is made by your liver. Cholesterol is used by the body to make cell membranes, hormones, and along with sunlight, produce vitamin D. The liver also uses cholesterol to make bile used for digestion. Triglycerides either are produced by the liver, or come from fatty foods, refined carbohydrates, or refined sugar. Triglycerides are used by the body to provide energy.

 

Lipoproteins are made by the liver by combining lipids and proteins in the liver. A lipoprotein named very low density lipoproteins or VLDL, is made in the liver and transports triglycerides to where they are needed by the body. If the body consumes an excess of triglycerides, the VLDL will store them as body fat. Once the VLDL loses the triglyceride it becomes low density lipoprotein or LDL, also known as bad cholesterol. If the body produces too much LDL, this (bad) cholesterol circulates in the blood, and may slowly build up in the inner walls of the arteries that feed the heart and brain. Together with other substances, cholesterol can form a thick, hard deposit called plaque that can narrow the arteries and make them less flexible. This condition is known as atherosclerosis. If a clot forms and blocks a narrowed artery in the heart or the arteries that lead to the brain, a heart attack or stroke can result. HDL or high density lipoprotein is known as good cholesterol, and is also produced in the liver. HDL may transport the extra cholesterol away from blood vessels to the liver and eliminate it from the body.

 

Cause of Atherosclerosis:

Hyperlipidemia is a significant contributor to the atherosclerosis disease process which leads to hypertension, coronary heart disease, cerebrovascular disease, peripheral vascular disease, and diabetes mellitus. A world renowned Cardiologist, William C. Roberts, MD not only described atherosclerosis as the leading cause of heart attacks, stroke, and peripheral vascular disease, he also claimed that cholesterol intake causes atherosclerosis. According to this author, the evidence which supports that cholesterol results in atherosclerosis include a higher frequency of atherosclerotic events in populations with relatively high cholesterol levels compared with populations with relatively low cholesterol levels. Atherosclerosis is easily produced in herbivores (rabbits, monkeys) by feeding them a high-cholesterol (egg yolks) or high-saturated-fat (animal fat) diet. Lowering total cholesterol and low-density lipoprotein (LDL) cholesterol levels decreases first and repeat atherosclerotic events and decreases plaque size. Furthermore, societies with a high frequency of hypertension or a high frequency of cigarette smoking but low cholesterol levels rarely get atherosclerosis. Therefore, to decrease the risk of atherosclerotic events, Roberts recommends that LDL cholesterol needs to be <100 mg/dL and ideally <70 mg/dL. Total cholesterol should be <150 mg/dL, and the high-density lipoprotein (HDL) cholesterol >20 mg/dL. The low HDL goal is rationalized by the author that levels below 20 are not dangerous if LDL and total cholesterol is also low. (1)

 

Hyperlipidemia goals of blood lipids:

Individuals age 20 -79 are recommended by the American Heart Association to have cholesterol levels checked every four to six years as part of a cardiovascular risk assessment. The Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol has established that the following lipid profile is optimal (as cited in Lichtenstein, 2006):

 

Cardiologist, William C. Roberts, MD views the lipid profile goals to be more strict than the AHA and he recommends the following (1):

 

Hyperlipidemia is a risk factor for coronary heart disease:

Coronary artery disease prevention and Integrative medicine therapy: Please see the section on coronary artery disease in Preventive Health Advisor.

 

The American Heart Association (AHA), hyperlipidemia, and coronary artery disease:

According to the American Heart Association (AHA), a favorable lipid profile is one of the important goals for prevention and reduction of risk for coronary heart disease (CHD) which include (3): 1) promotion of evidence-based dietary changes; 2) cardiopulmonary exercise; 3) achieving healthy bodyweight; 4) favorable lipid panel; 5) maintaining normal blood pressure; 6) avoidance of smoking; and 7) keeping blood glucose levels within normal range. (3)

 

American Heart Association (AHA) Scientific Statement, Diet and Lifestyle Recommendations:

Revision 2006 by Lichtenstein, AH et al for cardiovascular disease includes (3):

Diet recommendations by the AHA:

 

Dietary adjustments for hyperlipidemia:

Preventive Health Advisor recommends a diet focused on weight loss for body mass index over 25 kg per meter squared for control of lipid levels, then continued weight loss to achieve ideal body weight. For adult patients with hyperlipidemia and other known risk factors for cardiovascular and diet-related chronic disease, the U.S. Preventive Services Task Force (USPSTF) recommends intensive behavioral dietary counseling, and primary care clinicians or other specialists such as nutritionists or dietitians are qualified to provide this counseling (5).

 

Reduction of fat intake and hyperlipidemia:

The Therapeutic Lifestyle Changes Diet for coronary heart disease improves the lipid profile (6,7):

This diet is consistent with the American Heart Association’s 2006 Diet and Lifestyle Recommendations which can reduce the risk of cardiovascular disease. The diet consists of cutting back sharply on saturated fat, which may elevate LDL cholesterol levels and increase the risk of heart attack and stroke. Intake of saturated fat is kept below 7% of the total calorie intake. Total fat intake should consist of 25-35% of daily total calories. Daily cholesterol intake should be kept below 200 milligrams. Sodium intake is limited to 2400 mg per day. Calorie intake should be kept to a level needed for maintaining healthy weight and reduce blood cholesterol level. (7)

 

Importance of reducing dietary fat intake:

Reducing dietary fat, LDL reduction, and arterial diameter: Fourteen patients with slightly elevated levels of low-density lipoproteins (LDL) and confirmed coronary atherosclerosis were treated with pharmacologic and non-pharmacologic interventions for 2 years. The subjects were evaluated by coronary angiogram before and after the 2 year University of California Davis Coronary Artery Disease Regression Program. During the study intervention, dietary fat intake was decreased by 58% and intensive risk factor reduction was implemented. LDL levels dropped from 120 mg/dL to 104 mg/dL (p = 0.05). After 24 months, there was a net increase in arterial diameter (regression) of 0.05 mm to 2.81 mm (p = 0.01). While there was no significant change in the average diameter of discrete stenosis (abnormal narrowing in a blood vessel), 1 of 8 mild lesions < or = 20% regressed, while 4 progressed. The intervention resulted in regression of more severe lesions (> 50% initial stenosis), but does not appear to prevent progression of mild lesions (< 20%). These findings suggest that in patients with only mild elevation of lipids, the modification of risk factors improves the biology of the most severe lesions. (8)

 

Weickert reviewed the following dietary changes and described the expected results from some of these changes (9):

 

Dietary changes for diabetes patients with hyperlipidemia:

 

American Diabetes Association diet vs. vegan diet:

The effects of diet on glucose control, body weight, and plasma lipids were examined among individuals with type 2 diabetes for 74 weeks. Participants were randomly assigned to a low-fat vegan diet (n=42) or a standard diabetes diet based on the 2003 American Diabetes Association guidelines (n=50). Glycated hemoglobin (HbA1c), plasma lipids, and weight were measured. At the end of the study period, weight significantly decreased by 4.4 kg and 3.9 kg in the vegan and conventional groups, respectively. For participants on the vegan diet, total cholesterol and LDL cholesterol decreased by 20.4 mg/dL and 13.5 mg/dL, respectively. Corresponding values for those on the conventional diet was a decrease of 6.8 mg/dL and 3.4 mg/dL. In conclusion changes in overall lifestyle that include a vegan or nearly-vegan diet may be effective in improving the health of patients with diabetes. (11)

 

Common food sources with high cholesterol (12):

Turkey, whole, giblets, cooked, simmered, 1 cup 755 mg
Chicken, broilers or fryers, giblets, cooked, simmered, 1 cup 641 mg
Beef, variety meats and by-products, liver, cooked, pan-fried, 3 oz 324 mg
Fast Foods, biscuit, with egg and sausage, 1 biscuit 290 mg
Fast foods, english muffin, with egg, cheese, and Canadian bacon, 1 muffin 230 mg
Egg, whole, raw, fresh, extra-large 216 mg
Fast foods, croissant, with egg, cheese, and bacon, 1 croissant 215 mg
Crustaceans, shrimp, mixed species, canned, 3 oz 214 mg
Duck, domesticated, meat only, cooked, roasted, 1/2 duck 197 mg
Turkey from whole, neck, meat only, cooked, simmered, 1 neck 195 mg
Egg, whole, cooked, hard-boiled, 1 large 187 mg
Egg, whole, raw, fresh, 1 large 186 mg
Egg, whole, cooked, poached, 1 large 185 mg
Egg, whole, cooked, fried, 1 large 184 mg
Egg, yolk, raw, fresh, 1 large 180 mg
Potato salad, home-prepared, 1 cup 170 mg
Egg, whole, cooked, scrambled, 1 large 169 mg
Egg, whole, raw, fresh, 1 medium 164 mg
Spinach soufflé, 1 cup 160 mg
Eggnog, 1 cup 150 mg
Fast foods, chili con carne, 1 cup 134 mg
Crustaceans, crab, blue, canned, 1 cup 131 mg
Eclairs, custard-filled with chocolate glaze, prepared from recipe, 1 eclair 127 mg
Cheese, ricotta, whole milk, 1 cup 125 mg
Crustaceans, lobster, northern, cooked, moist heat, 3 oz 124 mg
Fast foods, hamburger; double patty w/ condiments/vegetables, 1 sandwich 122 mg
Fish, sardine, Atlantic, canned in oil, drained solids with bone, 3 oz 121 mg
Chicken, broilers or fryers, breast, meat and skin, fried, batter, 1/2 breast 119 mg
Crustaceans, shrimp, mixed species, cooked, breaded and fried, 3 oz 117 mg
Chicken, stewing, meat only, cooked, stewed, 1 cup 116 mg
Fast foods, french toast with butter, 2 slices 116 mg
Veal, leg (top round), separable lean and fat, cooked, braised, 3 oz 114 mg
Chicken, liver, all classes, cooked, simmered, 1 liver 110 mg
Cake, sponge, prepared from recipe, 1 piece 107 mg
Pie, pecan, prepared from recipe, 1 piece 106 mg
Milk, canned, condensed, sweetened, 1 cup 104 mg
Fast foods, hamburger; double, regular patty; w/ condiments, 1 sandwich 103 mg
Pork, fresh, spareribs, separable lean and fat, cooked, braised, 3 oz 103 mg
Lamb, domestic, shoulder, arm, trimmed to 1/4″ fat, choice, braised, 3 oz 103 mg
Braunschweiger (a liver sausage), pork, 2 slices 102 mg
Lamb, domestic, shoulder, arm, trimmed to 1/4″ fat, choice, braised, 3 oz 102 mg
Fish, haddock, cooked, dry heat, 1 fillet 99 mg
Fast foods, salad, vegetable, tossed, no dressing, w/ cheese and egg, 1-1/2 cups 98 mg
Fish, salmon, sockeye, cooked, dry heat, 1/2 fillet 98 mg
Fast foods, cheeseburger; large patty; w/ condiments/bacon, 1 sandwich 98 mg

Adapted from Nutritive Value of Foods, United States Department of Agriculture, Agricultural Research Service, Home and Garden Bulletin Number 72. May be accessed at: https://www.ars.usda.gov/SP2UserFiles/Place/12354500/Data/SR25/nutrlist/sr25w601.pdf

 

Aerobic exercise for hyperlipidemia and cardiovascular disease prevention:

For an in-depth look at benefits of aerobic exercise, please see the aerobic exercise section in Preventive Health Advisor. Preventive Health Advisor recommends a combined aerobic and resistance exercise program for all ages, but patients should seek approval by the primary physician prior to starting an exercise program. Aerobic exercise generally consists of mild to moderate intensity activity with rhythmic contraction of major muscle groups over an extended period of time. Examples include fast walking, jogging, cycling, Zumba, cross country skiing, and swimming. For the  physician or fitness professional, the following source is the most credible reference for initiation of exercise in patients: Walter R. Thompson, American College of Sports Medicine, Neil F. Gordon, Linda S. Pescatello. ACSM’s Guidelines for Exercise Testing and Prescription. Lippincott Williams & Wilkins, Feb 1, 2009. (13)

 

Benefits of aerobic exercise:

The many benefits of aerobic exercise in cardiopulmonary (heart and lung) conditioning include: improved pumping efficiency of the heart, improved circulatory system (14), weight control (15), cholesterol reduction (15,16), triglyceride lowering (15), lowering of blood pressure (17), lower rate of smoking (20),  and control of diabetes (18,19). Aerobic exercise results in reduction of cardiac mortality and all-cause mortality (20).

 

According to the World Health Organization:

According to the World Health Organization, regular exercise is recommended for not only all healthy individuals, but also those suffering from obesity, diabetes, hypertension, atherosclerotic cardiovascular disease and cancer. (21)

 

Starting exercise in apparently healthy adults:

According to the American College of Sports Medicine (ACSM) and the American Heart Association (AHA), older adults need moderate-intensity (between 5-6 on a 10-point scale) aerobic endurance activity for a minimum of 30 min which can be achieved in short 10 minute sessions on five days each week or vigorous-intensity aerobic, (rated a 7-8 on a 10-point scale) activity for a minimum of 20 min on 3 days each week.

 

Evidence-based benefits of aerobic exercise on hyperlipidemia:

A brisk half-an-hour walk every day can significantly reduce blood lipids (18). According to the American College of Sports Medicine and the American Heart Association (AHA), moderate-intensity aerobic activity, preferably every day of the week, for a minimum of 30 minutes per day is recommended to improve and maintain cholesterol levels in adults (16).

 

Cardiac Stress Testing:

Seek approval by the primary physician prior to starting an exercise program. Stress testing should be conducted in any patient with the following conditions (139,140):

 

American College of Sports Medicine (ACSM) Cardiorespiratory Training Guidelines:

After approval from the physician is obtained, training guidelines should be followed. The main components of an exercise session per ACSM include warm-up, conditioning stimulus, and cool down. Warm-up before the session and cool down after the session of exercise consists of 5-15 minutes of activity at 50% training intensity of the conditioning activity planned. One should be easily able to hold conversation at 50% intensity.

 

Aerobic Exercise Intensity:

How to determine aerobic exercise intensity according to the American College of Sports Medicine (ACSM):

 

An example in determining aerobic exercise intensity is as follows. A 60 year old male beginner would calculate his training intensity assuming a stress test was done for multiple risk factors for heart disease as follows:

 

Aerobic Exercise Training Progression

Training should then progress to experience cumulative improvement in cardiorespiratory conditioning. Training progression according to the ACSM consists of the 3 stages below:

 

Power Walking:

Power walking is an effective initial aerobic activity for beginners. Start walking at a normal pace and continue to increase the walking speed over 10 minutes to reach a heart rate of 110 – 120 beats per minute resulting in mild perspiration.

 

Aerobic exercise is covered in more detail elsewhere in Preventive Health Advisor.

 

Aerobic exercise, weight loss and cholesterol control:

A study done by Barnard, et al. compared 51 to 64 year old subjects from an exercise group that did a consistent exercise program for at least 10 years, a diet plus exercise group who did a consistent diet and exercise program for at least 10 years, and a sedentary group with poor diet. Based on this used as a comparison, if someone began to exercise 5 days per week for one hour in their 50s for 10 years without a change in diet, they should expect to decrease their body mass index about 11.5 kg/m^2, reduce total cholesterol by about 11 points, and reduce their triglycerides by about 105 mg/dl. There was no large benefit in LDL and HDL cholesterol seen in the group which consumed a poor diet. If someone began to exercise 4-6 days per week for one hour in their 50s for 10 years with eating a low fat, high fiber and complex carbohydrates diet along with exercise they would attain the following average benefit. A decrease in their body mass index about 16.5 kg/m^2, reduce total cholesterol by about 33 points, reduce LDL cholesterol by about 20 points, and reduce their triglycerides by about 109 mg/dl. There was no large benefit in HDL cholesterol seen in this study.(15)

 

Cardiac rehab programs, aerobic exercise and hyperlipidemia:

A systematic review and meta-analysis of randomized controlled trials by Taylor et al found that exercise based cardiac rehabilitation reduces all cause and cardiac mortality and resulted in significant reductions in total cholesterol of 0.37 mmol/L and triglyceride concentrations by 0.23 mmol/L. There were no significant differences were seen in low or high-density lipoprotein concentrations in this analysis. (20)

Silberman and colleagues reported the results of an analysis of patients (n=2974) participating in an intensive cardiac rehabilitation program. The authors reported significant improvements in body mass index (BMI), triglycerides, low density lipoprotein cholesterol, total cholesterol, hemoglobin A1c, systolic blood pressure, diastolic blood pressure, depression, hostility, exercise, and functional capacity at 12 weeks and 1 year. (22)

 

Resistance training, protein supplements, and hyperlipidemia:

Preventive Health Advisor recommends a combined aerobic and resistance exercise program with or without a protein supplement for patients of all ages if approved by the primary care physician. Overweight hypercholesterolemic men with serum cholesterol over 200 mg/dl were randomly divided into 3 groups (placebo (n = 9), soy (n = 9) or whey (n = 10) supplementation of 26 grams of protein per day to maintain protein intake of 1.2 grams per kg daily. The men participated in supervised resistance training for 12 weeks. Total serum cholesterol decreased significantly (average=5.8%) for all groups (mean reduction = 12.6 mg/dL), with no differences among groups. Specifically, total cholesterol reduction was 10.4 mg/dL for placebo, 11.2 mg/dL for soy, and 15.9 mg/dL for whey. Participation in a 12 week resistance exercise training program significantly reduced serum cholesterol, increased strength, and improved body composition in overweight, hypercholesterolemic men. Whey protein with resistance training improved cholesterol more than placebo or soy protein. (23)

 

Evidence-based diet plus exercise programs for hyperlipidemia and coronary artery disease:

Preventive Health Advisor views both dietary changes and an exercise program of vital importance for control of hyperlipidemia. We believe that striving for an ideal diet alone will have a greater health benefit than exercise alone, but if both aspects are combined, then these health benefits will be greatly potentiated.

 

The Pritikin Program lipid profile benefits:

A study using 67 patients with metabolic syndrome to investigate the effects of Pritikin therapy for 12-15 days showed improvement in LDL cholesterol (25,26), showed 10%-15% reduction of LDL (24), and lowered triglycerides (36% reduction) (33). Additionally, 37% of subjects no longer met the criteria for metabolic syndrome as determined by the National Cholesterol Education Program. HDL cholesterol decreased by 3%. (24)

The Centers for Medicare and Medicaid Services review of published data on the Pritikin intensive cardiac rehabilitation programs found that it effectively reduced LDL cholesterol levels (25,26), total cholesterol (26), and the need for cholesterol medications (25).

 

Pritikin Diet characteristics (24,25,26):

 

Insurance approval for the Pritikin Program:

Medicare may approve coverage for the Pritikin Program for qualifying individuals with a history or risk of cardiovascular events. The program has been approved for coverage under Part B of Medicare. Medicare will reimburse eligible beneficiaries for up to 72 one-hour ICR sessions, up to 6 sessions per day, at the Pritikin Longevity Center & Spa.

 

The Dean Ornish Program for reversing heart disease evaluated 3,780 patients: (27):

 

Insurance approval for the Ornish Program:

Medicare Part B covers The Dean Ornish Program for Reversing Heart Disease, under a new benefit category, Intensive Cardiac Rehabilitation (ICR). Eligibility includes acute myocardial infarction within the preceding 12 months, a coronary artery bypass surgery, current stable angina pectoris, heart valve repair or replacement, percutaneous transluminal coronary angioplasty or coronary stenting, a heart or heart-lung transplant, or other cardiac conditions as specified through a national coverage determination. (27)

 

The Therapeutic Lifestyle Changes Diet plus exercise:

The effect of adding 30 minutes of daily exercise at 50-75% of age-predicted maximum heart rate, to a Therapeutic Lifestyle Changes Diet (TLC) for 6 months was examined by Welty, FK et al. The authors of the study randomized participants with high-normal or stage 1 hypertension to either a treatment diet rich in fruit, vegetables, low-fat dairy products, reduced saturated/total fat or a control diet low in fruit, vegetables, and dairy products with fat content typical of the average US diet. A TLC diet with the addition of exercise assisted 89% of participants to reach an LDL cholesterol goal of under 130 mg/dL without lowering HDL levels or needing to add or increase lipid lowering therapy. The authors emphasized that exercise and weight loss should be encouraged with the TLC diet to achieve the LDL goal. Mean total cholesterol, LDL cholesterol and triglycerides decreased by 9.2% (p=0.08), 9.3% (p<0.018), and 18.8% (p<0.05), respectively; mean HDL cholesterol increased 2.6% (p=0.41). Women had a 12.3% reduction in LDL cholesterol and an 11.4% increase in HDL cholesterol compared with a 7.9% reduction in LDL cholesterol and no change in HDL cholesterol in men. Additionally, systolic and diastolic blood pressure (BP) decreased 9% (p<0.001) and 13%, respectively (p <0.0001). These BP reductions were two-fold greater than in the Diet and Systolic Hypertension study (DASH) The addition of exercise also achieved a 50% reduction in angina. (6)

 

Specific evidence-based foods for hyperlipidemia and coronary heart disease:

Nut consumption, hyperlipidemia, and the risk of coronary events:

According to Fraser, GE research has shown that consumption of almond and walnuts, instead of more traditional fats, is linked to an 8% to 12% reduction in LDL cholesterol.  Macadamias and hazelnuts have been shown to be at least as beneficial as fats in commonly recommended diets. Other studies have reported that frequent consumption of nuts were linked with a 30% to 50% decreased risk of coronary heart disease. Additionally, the Dietary Approaches to Stop Hypertension (DASH) diet recommends regular consumption of nuts with seeds and dried beans (4-5 servings per week) as part of a diet to control hypertension. (28)

There is consistent evidence from epidemiologic and clinical studies that tree nuts and peanuts reduce the risk of developing coronary heart disease (CHD) and also have beneficial effects on hyperlipidemia. Nuts lower total and LDL cholesterol to a greater extent than expected based on their favorable fatty acid profile and also appear to contain other bioactive compounds with cholesterol-lowering properties. Including nuts and peanuts in a healthy diet may decrease the risk of CHD. (29)

 

Oats for treatment of high cholesterol:

Consumption of oats and other whole grains may reduce the effects on major risk factors for cardiovascular disease (CVD), in adults with high cholesterol. Men and women with mild to moderate high cholesterol were included in two groups: an oat group (n=85) who consumed 100 grams of instant oat cereal or control group (n=81) who consumed 100 grams of wheat flour-based noodles daily for 6 weeks. In the oat group, dietary fiber intake increased significantly and total cholesterol decreased significantly by 6.2% compared to a 2.3% decrease in the control group. LDL cholesterol also decreased significantly by 8.4% compared to a 3.5% decrease in the control group. Conversely, HDL cholesterol decreased significantly in the control group versus the oat group. (30)

A review of studies on oat β-glucan, soluble fiber found in oats, found that consuming 3g oat β-glucan daily is considered sufficient to lower LDL cholesterol by 5%-10% in individuals with normal or high cholesterol. Additionally, the US Food and Drug Administration (in 1997) and the UK Joint Health Claims Initiative (in 2004) approved the claim of oat β-glucan as a cholesterol-lowering ingredient. (31)

A randomized, controlled clinical trial on 112 subjects evaluated the effect of a 6-week low fat, low saturated fat diet that contained oil-based phytosterols (TOP) and oat β-glucan (from whole oats and bran) on blood lipid (fat) levels in adults with elevated cholesterol. The diet consisted of food products (cereal, snack bar and beverage) that provided 1.8 g TOP and 2.8 g beta-glucan/d and contained < or =3.0 g total fat and < or =1.0 g saturated fat or similar control foods. Results found that the blood LDL cholesterol response was significantly larger in the β-glucan treated group than in the control group, in which there was no change (-3.7 vs. 0.4%). Total cholesterol also decreased in the β-glucan group and did not change significantly in the controls (-2.3 vs. 0.8%). (32)

In a study by Keenan et al, participants were randomized to the oat cereal group (5.52 g/day β-glucan) or to a low-fiber cereal control group (< 1.0 g/day total fiber) for 6 weeks. Eating oats can reduce systolic pressure by as much as 7.5 points and diastolic pressure by 5.5 points according to a study of 18 hypertensive individuals with hyperinsulinemia. Additionally, consumption of oats was associated with a significant decrease in both total cholesterol (9%) and LDL cholesterol (14%). There was also a trend toward improved insulin sensitivity but could not be calculated due to a small number of subjects. (33)

A study of the cholesterol-lowing effects of β-glucan in 36 individuals with elevated cholesterol did not find any significant change in concentrations cholesterol during consumption of 10 g/d β-glucan rich oat bran (n = 20, subjects) or wheat bran (n = 16) for 8 wk. However, In the oat-bran group, but not in the wheat bran group, serum total cholesterol declined transiently. (34)

 

Soy isoflavones, flavonoids, and cholesterol:

In total 115 women participated in a cross-sectional study investigating the intake of the phytochemicals flavonols, flavones and isoflavones with blood chemistry data. Flavonoids (flavonols, flavones) and isoflavones are the anti-oxidant phytochemicals, chemical compounds produced by plants, found in many foods such as apples, cabbage, onions, parsley, pinto beans, and tomatoes. The main sources of flavonoid consumption in this study were vegetables (72.3%), fruits (15.6%), green tea (5.4%), potatoes (3.8%) and pulses (tofu) (2.9%). A 3-day dietary intake was recorded and urine and blood samples were taken after that period. Researchers found that the mean intake of flavonoids was 16.7 mg/d and the mean intake of isoflavones was 47.2 mg/d. The following phytochemicals were determined to make up the total flavonoid intake: quercetin (55.9%), kaempferol (35.3%), fisetin (4.6%), myricetin (2.5%), and luteolin (1.7%). Most of the flavonoids came from onion consumption 45.9%, 23.1 g/d) followed by molokheya, a dark leafy green, (9.7%, 4.6 g/d), apples (7.2%, 22.2 g/d) and green tea (5.4%, 206 mL/d). The study concluded that the intake of flavonoids was inversely related with LDL cholesterol. Intake of other phytochemicals was not correlated with lipid levels. In this particular study, there was no correlation between green tea consumption and plasma lipids. (35)

A double-blind randomized parallel trial of 156 healthy men and women with LDL cholesterol levels between 3.62 mmol/L (140 mg/dL) and 5.17 mmol/L (200 mg/dL) were studied to identify the the link between isoflavones isolated together with soy protein or soy protein itself and cholesterol. Participants were randomly assigned to one of 5 daily diets: 25 g of casein [for isoflavone-free comparison] or 25 g of isolated soy protein containing 3, 27, 37, or 62 mg of isoflavones. Crouse et al found significant decreases, compared with casein, in LDL cholesterol after the consumption of isolated soy protein containing 62 mg isoflavones (4% vs 6%, respectively) but not after the consumption of that containing 37, 27, or 3 mg isoflavones. These results support the conclusion that isolated soy protein containing isoflavones lowers cholesterol. Isolated soy protein containing isoflavones were also found to not have a harmful affect on plasma concentrations of triglycerides or HDL, cholesterol. (36)

Soy protein and coronary artery disease: The Food and Drug Administration (FDA) has approved a statement on food labels that soy protein may reduce the risk of coronary artery disease by lowering cholesterol levels when included in a diet low in saturated fat and cholesterol. (37)

 

Guar gum ( a type of glucomannan) and high cholesterol:

In individuals with type 2 diabetes (n=16), guar gum (Guarina) significantly improved fasting blood sugar and HbAlc (a measure how well diabetes is being controlled).  Participants were administered either Guarina (G) or placebo for 2 periods of 8-weeks. Compared to placebo, fasting blood sugar levels were significantly reduced to 151.7 mg/dL by G (vs 168.6 mg/dL for placebo). G supplementation also significantly reduced HbAlc (by 6.9%) and fasting insulin levels (by 18.3 U/ml). Total cholesterol, triglyceride, HDL cholesterol, LDL cholesterol, salt, potassium, chloride, magnesium and calcium levels were not affected by either placebo or G. Side-effects were reported in 62.5% of patients receiving Guarina and included abdominal cramps, diarrhea (most common), and skin itching. (38)

Guar may help improve blood sugar (glucose) levels in patients with diabetes. In this study 20 participants (n=12 non-insulin-treated and 8 insulin-treated) received 10 g/d granulated guar for 2 months. After one month, average glycosylated hemoglobin levels (HbA1c%) were significantly reduced by 0.6% and by 1% after 2 months. After guar administration was stopped, HbA1c% rose to its pre-guar level of 11.1%. (39)

Guar gum was shown to improve blood sugar levels, need for insulin, and levels of total cholesterol in patients with type 1 diabetes.  Guar gum or placebo was administered to patients 4 times/day for 4 weeks. After guar administration, following breakfast and lunch, blood sugar levels and insulin needs were significantly reduced compared to placebo. Guar was also associated with a reduction in total cholesterol of 21%. (40)

Fiber-containing nutrition bars containing guar gum viscous fiber were found to decreased hunger and increased fullness in type 2 diabetics in this study (n=99). Participants ate 300-calorie candy bars for lunch and reported a 27.1% increase in fullness, a 15.8% decrease in food intake, and a 14.2% decrease in hunger two to four hours after the fiber-containing nutrition bars. Results indicate that guar gum may be a useful for managing type 2 diabetes by promoting weight loss. (141)

Guar gum, derived from guar beans, is an herbal medicine found to improve long-term control of blood sugar levels (glycemic control), measures of blood glucose after eating (postprandial glucose tolerance), and lipid (fat) concentrations in 15 individuals (aged 45-70 years old, 8 male) with non-insulin-dependent diabetes mellitus. Participants started on placebo for 8-weeks (period 1) followed by 42-weeks of daily guar gum (15 g) treatment and finishing with another 8-week placebo (period 2). Glycosylated HbA1 concentration, measure of blood sugar, significantly decreased from 9.0% during period 1 to 8.5% during guar gum treatment and remained at this level. A decrease of fasting blood sugar, though not significant, was also reported between period 1 and guar gum treatment (9.5 mmol/L and 9.2 mmol/L, respectively). Also, a significant increase to 10.4 mmol/L was reported between guar treatment and period 2. Compared to guar gum treatment, average total cholesterol during period 1 and period 2 were significantly reduce to 5.74 mmol/L and 6.61 mmol/L, respectively. LDL cholesterol fell significantly from 3.90 mmol/L during period 1 to 3.57 mmol/L during guar gum treatment. During period 2 the LDL cholesterol concentration increased to 4.32 mmol/L. Average HDL-cholesterol concentrations showed a steady non-significant increase during the study (period 1, 1.18 mmol/L; guar gum treatment, 1.26 mmol/L; period 2, 1.33). Some minor side-effects reported throughout the study included flatulence, loose stools, and a feeling of stomach discomfort. (42)

A double-blind placebo-controlled, cross-over study of 25 healthy normal weight middle-aged men found that 30 g/d of guar gum derived from guar beans, improved blood pressure, blood glucose, cholesterol, and triglycerides, leading the authors to recommend guar gum for people with insulin resistance, a group of health risk factors that increase the likelihood of heart disease and diabetes. Study participants underwent a regimen of 2-weeks without treatment followed by 6 weeks of placebo or treatment 3 times a day. Compared to placebo, guar treatment was significantly associated with a the following: a 0.3 mmol/L decrease in fasting blood sugar, a 0.6 mmol/L decrease in cholesterol, a 0.2 mmol/L decrease in triglycerides, a 2.9 mU/L decrease in plasminogen activator inhibitor-1 activity (important component of blood clotting), a decrease in systolic and diastolic blood pressure (6 mmHg and 3 mmHg, respectively), and an increase in insulin sensitivity, measured with the euglycemic-clamp technique (the less glucose that’s taken up by tissues during the procedure, the more insulin resistant a patient is), of 1.2 mg . kg lean body mass-1 . min-1. (43)

 

Psyllium fiber treatment and the lipid profile:

Psyllium, a dietary fiber, produced a modest but significant improvement in total cholesterol and LDL cholesterol levels in persons on either low-fat or high-fat diets. Sprecher and collegeaus reported that after 8 weeks of treatment (5.1 g of psyllium twice daily)  total and LDL-cholesterol concentrations were lower by 5.8% and 7.2%, respectively, in individuals on high-fat diets and 4.2% and 6.4%, respectively, in individuals on low-fat diets. Additionally, 39% of the psyllium recipients improved in LDL cholesterol classification (based on the National Cholesterol Education Program classification system) compared with 20.3% of those on placebo. (131)

Psyllium, a dietary fiber, was shown to lower cholesterol in persons with mild-to-moderate high cholesterol on a low-fat diet in this meta-analysis that included 8 studies (n=656). For a minimum of 8 weeks participants on a low-fat diet received either psyllium 10.2 g/day (n=384) or placebo (n=272). Compared to the placebo group, psyllium significantly lowered total cholesterol by 4%, LDL cholesterol by 7%, and the ratio of apolipoprotein (apo) B to apo A-I (a predictor of coronary heart disease) by 6%. No change in HDL cholesterol or trig;yceride levels was reported. Overall psyllium was well tolerated. (45)

Significant reductions in total and LDL cholesterol levels in individuals with high cholesterol were reported after 26 weeks of treatment with 5.1 g psyllium, a dietary fiber, twice daily.  Participants were randomly assigned to receive either psyllium or placebo and continue following an American Heart Association Step I diet. Compared to the placebo group, after 24-26 weeks, total and LDL-cholesterol levels were reported to be 4.7% and 6.7% lower. (46)

A study of 7 men on a 3 week nutritionally controlled diet followed by an addition of 21 g/day of psyllium, a dietary fiber, to their diet for 3 weeks found total cholesterol, LDL cholesterol, and HDL cholesterol were reduced. After 10 days, total was 35 mg/dL and after 3 weeks it had been further reduced to 30 mg/dL. After 3 weeks, LDL cholesterol was reduced by 15 mg/dL and HDL was reduced by 4 mg/dL. (134)

The hypocholesterolemic (low cholesterol) effects of psyllium and pectin enriched (both soluble fibers) cereals were examined in this randomized, controlled study (n=58 men). Following a diet only phase (6 weeks minimum), either corn flakes or pectin enriched or psyllium enriched cereal was randomly added to a participant’s diet for 6 more weeks. Following the diet only, total cholesterol was reduced by 3.8%. Following the addition of cereal, researchers found that the psyllium enriched cereal lowered cholesterol more effectively (total cholesterol, -5.9%; LDL cholesterol -5.7%) than the pectin enriched cereal (total cholesterol, -2.1%; LDL cholesterol -3.9%). (48)

 

Psyllium, guar gum and insulin levels:

Research into the inclusion of ispaghula husk (also known as psyllium or brand name Metamucil) and guar gum in the diet of 10 healthy women aged 30-48 years old concluded that postprandial glucose and insulin concentrations (sugar and insulin levels after a meal) were reduced. After an overnight fast participants took fiber in the morning. Average insulin levels were lowered from 30 to 90 minutes after administration of both fibers. (49)

 

Psyllium and diabetes:

Psyllium, a soluble fiber used as laxative also known as ispaghula husk or brand Metamucil, was studied in a double-blind placebo-controlled study for its effect on fat and sugar levels in 49 patients with type 2 diabetes.  Participants were given their normal anti-diabetic drugs plus they were randomized to receive either 5.1g psyllium (Plantago ovata Forsk) twice per day (a half hour before breakfast and dinner) or placebo. At the end of the study, participants in the psyllium group showed a significant reduction in fasting blood sugar levels and average level of blood sugar as measured by glycosylated hemoglobin (HbA1c). Both of these results suggest an improvement in blood sugar control. Additionally, HDL cholesterol was reported to increase significantly with psyllium. (50)

 

Konjac glucomannan, diabetes, cholesterol control:

Glucomannan is a water-soluble dietary fiber that is derived from the konjac root.

A meta-analysis of 14 studies (n=531) found that glucomannan, a water-soluble dietary fiber that is derived from the konjac root, has a beneficial affect on total cholesterol, LDL cholesterol, triglycerides, body weight, and fasting blood glucose (FBG). Dosage used was a range of 1.2 to 15.1 grams per day. However, HDL cholesterol or blood pressure (BP) were unaffected by glucomannan. The average benefit, taking all study results into account, associated with glucomannan include decreases in total cholesterol by -19.28 mg/dL, in LDL cholesterol by -15.99 mg/dL, in triglycerides by -11.08 mg/dL, in body weight by – 0.79 kg (-1.74 lbs), and in FBG by -7.44 mg/dL. No effect on HDL or blood pressure was seen. (51)

Taking glucomannan, a water-soluble dietary fiber that is derived from the konjac root, in combination with plant sterols (naturally occurring compounds with cholesterol-lowering effects) may help diabetes patients keep their cholesterol in check. For the study, 16 diabetes patients and 18 non-diabetic individuals were assigned to one of four treatments for 21 days: supplements containing plant sterols (1.8 g/day), supplements containing glucomannan (10 g/day), supplements containing a combination of glucomannan and plant sterols, or a placebo. Results indicated that the combination of glucomannan and plant sterols was most effective at lowering LDL cholesterol. LDL cholesterol was 3.16 mmol/L after glucomannan, 2.95 mmol/L after glucomannan plus plant sterols, and 3.60 mmol/L after placebo. Total cholesterol was also lower after glucomannan plus sterols (4.72 mmol/L) compared to placebo (5.47 mmol/L). (52)

Four weeks of treatment with glucomannan (3.6 g/day), a water-soluble dietary fiber that is derived from the konjac root, was found to help guard against elevated glucose (sugar) levels and improve cholesterol levels in diabetes patients. The study involved 22 diabetes patients with high cholesterol who were not taking cholesterol medication. Results showed that glucomannan was superior to placebo in significantly reducing LDL cholesterol by 20.7% and fasting glucose levels (a measure of blood sugar after not eating or drinking for at least eight hours) by 23.3%. (53)

Glucomannan may help control diabetes. In a study, 11 type 2 diabetes patients with hyperlipidemia (high lipid levels especially cholesterol) and hypertension ate either glucomannan-enriched biscuits (0.7 g/412 kJ [100 kcal] of glucomannan) or placebo wheat bran fiber biscuits every day for three weeks. Researchers found that compared to placebo, consumption of the glucomannan-enriched significantly improvement blood sugar control ( by 5.7%), decreased cholesterol, and decreased systolic blood pressure (6.9%). (54)

Glucomannan at a dose of 1240 mg to 4320 mg per day plus a low-calorie diet (1200 kcal) was more effective than placebo and a low calorie diet for improvement in body weight, total cholesterol, and hunger/satiety (55). Weight loss contributes to improvement of hyperlipidemia. Weight loss over 5 weeks was 3.8–4.4 kg with the doses of glucomannan mentioned above (55)

Glucomannan and a low-calorie diet (1200 kcal) was more effective than placebo and a low calorie diet for improvement in body weight, total cholesterol, and hunger/satiety in a 60-day study that included 30 participants (56).

 

Guar gum, psyllium, and glucomannan fiber adverse reactions and interactions:

Dry powdered fibers are generally safe when mixed with adequate water or another liquid, but these are not without health risks. At least 8 ounces of fluid is recommended when taking dry fibers such as glucomannan, Konjac root, guar gum, Citrucel, and psyllium (Metamucil). Fibers are natural, but they are not without health risks. Health Canada issued a warning that glucomannan fiber caused choking, obstruction of the throat, esophagus or bowels according to reports when not consumed with adequate amount of fluid (57). The warning also stated that the fiber should not be taken before bed. Fibers may also bind medications and interfere with absorption resulting in a reduction in the desired effect of the medication. Therefore, it may be best to take medications 2 hours before or after the fiber is taken.

 

Increasing HDL cholesterol with niacin:

Niacin is one of the strongest acting agents known to increase high-density lipoprotein (HDL) and is the recommended treatment to lower lipoprotein (a) which helps reduce the risk of heart disease (58,59), and result in less cardiac events (62). Niacin also lowers LDL cholesterol a small amount (60).

 

Immediate release niacin vs. sustained release niacin:

A study compared both immediate release and sustained release niacin therapy starting at 500 mg with a dose escalation every 6 weeks up to 3000 mg yielded the following results (61):

 

Expected HDL improvement with niacin:

Use of niacin, vitamin B3, in patients with cardiovascular disease (n=55) was associated with a 31% increase in high-density lipoprotein (HDL), at a dose of 1g low-dose long-acting niacin daily. Use of niacin showed no significant change in total cholesterol or triglyceride levels. Individuals not taking niacin (n=17) saw no change in lipid levels. 40% of subjects were reported to stop the drug due to side effects. (58)

 

Niacin added to statin therapy:

Extended-release niacin 1000 mg/day added to statin therapy in a double-blind randomized placebo-controlled trial over 1 year had the following results (62):

In a 3-year double-blinded, placebo-controlled trial by Brown et al, treatment with sustained release niacin added to simvastatin dramatically reduced cardiac events, improved stenosis of coronary arteries, and reduced LDL cholesterol (LDL-C) levels in coronary heart disease.

Brown, BG et al evaluated patients randomly assigned to 1 of 4 regimens with previous heart attacks, previous coronary intervention, and history of angina: simvastatin plus niacin, antioxidant vitamins, simvastatin–niacin plus antioxidants, or placebo. All patients also had at least one stenosis over 50% or 3 stenoses of at least 30%. If LDL-C was 110 mg/dL or lower at the start of the study, patients received 10 mg simvastatin and 20 mg if LDL-C was greater than 110 mg/dL. Patients receiving simvastatin (Zocor) had their dose titrated to a goal LDL-C level of 40 to 90 mg/dL. In the first year, if any patient had a LDL-C below 90 mg/dL, the simvastatin dose was increased by 10 mg/d and was decreased by 10 mg/d if LDL-C was below 40 mg/dL at any time. Placebo patients were given 10 mg simvastatin if LDL-C was greater than 140 mg/dL, with a target of 130 mg/dL or less. In patients receiving niacin, the dose was titrated over 1 month to at least 1000 mg twice per day (mean final dose 2.4 grams/day). Niacin 50 mg twice per day was used as the placebo to produce a flushing effect and thus keep patients blinded. Antioxidants were given twice daily, with total dosage of 800 IU vitamin E, 1000 mg vitamin C, 25 mg natural beta-carotene, and 100 μg selenium. Results revealed that major heart events were cut by 60-90% in patients taking simvastatin plus niacin. They also had significantly fewer cardiovascular events than those given placebo (21% vs 2.6%). However, addition of antioxidants actually reduced this effect: when antioxidant therapy was added to lipid lowering, the rate of clinical events increased to that observed with placebo. There was also no difference between patients receiving antioxidants alone and those receiving placebo. Patients receiving simvastatin plus niacin had small increases in aspartate aminotransferase (higher levels of this enzyme may signal heart or liver disease), creatine kinase (marker of heart, muscle damage), uric acid, homocysteine (high levels increase risk of heart attacks, strokes, blood clots), and insulin. (67)

 

Extended release niacin:

An analysis involved 432 participants with dyslipidemia who received extended-release niacin (500-3000 mg/day). Average reduction in LDL cholesterol was greater for women than for men at all doses: significant differences of 6.6% at 1000 mg, 5.7% at 1500 mg, 7.9% at 2000 mg and 11.0% at 3000 mg were reported. Triglyceride decreases also were greater for women than for men at all doses, although only the difference at 1500 mg/day reached significance (28.6% vs 20.4%). In conclusion, women respond as well, if not better, than men to extended-release niacin treatment. (60)

An individual responded well to 3 g/daily of immediate-release niacin, however after switching to same dose slow-release niacin the individual developed hepatitis. The authors caution that niacin is a drug and not a dietary supplement. The authors recommend use of immediate-release niacin beginning a therapy treatment with a dose of 2 g/daily. (63)

Sustained release niacin at 500 mg daily for 4 weeks followed by 1000 mg daily for 4 weeks resulted in compliance of over 90%, increased HDL by 17%, LDL decreased by 11%, and did not result in any significant transaminase elevations (64). Sustained release niacin dose should therefore be limited to 1000 mg daily because it is tolerated well and has less hepatotoxicity than higher doses (64).

 

Immediate release niacin:

The ADMIT study (Arterial Disease Multiple Intervention Trial), evaluated immediate release niacin at a dose escalation up to 3000 mg daily in a large study group for 48 weeks and found the following results (65):

 

Niacin and homocysteine:

Niacin administration is associated with increased plasma homocysteine levels in patients who have peripheral arterial disease (PAD, plaque build-up in the arteries), report the authors of this study of 55 participants from a randomized, placebo-controlled study. Niacin, increased daily from 100 mg to 1000 mg, was associated with a 17% increase in average homocysteine level. After 18 weeks on treatment, average homocysteine level in the niacin group had increased by 55% but in the placebo group the average level had decreased by 7%. This group difference was still present after 48 weeks of follow-up. (66)

 

Niacin adverse reactions and interactions:

 

Red wine consumption and the lipid profile:

Red wine both increases HDL cholesterol and decreases LDL cholesterol significantly. It is believed that the increase in HDL cholesterol with drinking alcohol containing beverages are responsible for 50% of red wine’s protective effect from coronary artery disease, and 50% may be due to the polyphenols in red wine which inhibit platelet aggregation (68).

Moderate red wine consumption has been associated with not only improved cholesterol profile, but also decreased cardiovascular risk, reduced mortality, improved bone density in older adults, and reduced risk of cancer esophageal and gastric cancer. Multiple studies have shown that red wine is more beneficial in reducing the risks of coronary artery disease (CAD) and mortality in general when compared with other alcoholic beverages such as spirits, beer and white wine. HDL cholesterol have been found to be increase with red wine consumption in numerous studies. (69)

A parallel four-armed intervention studied the relationship between cardiovascular disease (CVD) and wine drinkers. Sixty-nine men and women aged 38-74 years old were randomized to either 1: red wine (males: 300 ml/day, 38.3 g alcohol/day, female subjects: 200 ml/day, 25.5 g alcohol/day), 2: water + red grape extract tablets (wine-equivalent dose), 3: water + red grape extract tablets (half dose), or 4: water + placebo tablets. At the end of the 4-week study period, results showed that drinking red wine in moderation increased HDL cholesterol by 11–16% and decreased fibrinogen (a protein that plays a key role in blood clotting) by 8–15% compared with drinking water with or without red fermented grape extract. The findings suggest that it is the alcohol component of red wine that is causing these beneficial effects. In conclusion, moderate alcohol consumption in the form of red wine and other beverages is associated with beneficial changes in blood lipids and fibrinogen that may help to reduce the risk of CVD. (70)

The relation between red wine (polyphenolic extracts) and risk factors associated with cardiovascular disease was examined in this European project FAIR CT 97 3261. Results from a study of 40 healthy volunteers in Barcelona showed a significant increase in HDL cholesterol levels and a decreased oxidation of LDL cholesterol after red wine consumption (30 g alcohol daily for 4 weeks) as compared to the same amount of alcohol given as spirit such as vodka, whiskey, gin, tequila, and rum. (71)

The effects of dealcoholized red wine (DRW) and regular red wine (RW) on risk factors associated with cardiovascular disease (CVD) in 45 hypercholesterolemic (high cholesterol level) postmenopausal women were analyzed. Participants were randomized to 400 mL/day of either water, DRW or RW for 6 weeks on a controlled diet following a 4-week washout. At the end of the study period, concentrations of fasting lipids, lipoproteins, insulin and glucose were unaffected by DRW intake. However, chronic consumption of RW significantly decreased LDL cholesterol concentrations by 8% and increased HDL cholesterol concentrations by 17%.  In summary, regular consumption of red wine reduces CVD risk by improving fasting LDL and HDL levels in hypercholesterolemic postmenopausal women. (72)

Andrade, AC et al compared healthy adults with adults who had high blood pressure and/or high total cholesterol levels and found that the benefits of drinking red wine differed between these groups. Subjects with hypercholesterolemia (A, n=10) or arterial hypertension (B, n=9), or healthy controls (C, n=7) were given red wine (250 mL/night) for 15 days. At the end of the study period, total cholesterol in groups A and B decreased by 17 and 7 mg/dL, respectively. However, in group C (controls) it increased by 22 mg/dL. Red wine significantly increased HDL cholesterol in the controls by 7 mg/dL, but not in the other groups (A: -4 mg/dL, B: +1 mg/dL). LDL cholesterol decreased by 17 and 14 mg/dL in group A and B respectively. The LDL increased by 13 mg/dL in controls. The were no significant changes in hemodynamic measurements. Across all participants, mean blood pressure (BP) decreased 7 mm Hg (p <0.01) and systemic vascular resistance decreased 7% (p = 0.05). Triglycerides increased by 13 mg/dL in group A, 31 mg/dL in group B, and 11 mg/dL in group C, but triglycerides were less than 139 mg/dL in all groups. Heart rate and cardiac output did not significantly change in any group. (73)

 

Lowering elevated triglycerides:

Omega-3 fatty acids, triglycerides and coronary artery disease: Please see the section on omega-3 fatty acids for more information which includes omega-3 fatty acid adverse reactions and interactions. The United States Food and Drug Administration (FDA) approved omega-3 fatty acids for the treatment of high triglyceride levels (74).

The American Heart Association (AHA) omega-3 fish oil and fish consumption recommendations: The American Heart Association (AHA) recommends that all adults eat fish (particularly fatty fish) at least two times per week. The AHA also recommends eating plant-derived omega-3 fatty acids. Tofu and other forms of soybeans; walnuts and flaxseeds and their oils. For patients with coronary heart disease (CDH) it is recommended they consume about 1 gram of two kinds of omega-3 fatty acids shown to be cardio-protective. These include docosahexaenoic acid and eicosapentaenoic acid (DHA and EPA), which are found in oily fish species like mackerel, lake trout, herring, sardines, albacore tuna, and salmon. Patients needing triglyceride-lowering, should consult a physician. The AHA recommends a daily intake of 2-4 grams of EPA+DHA for elevated triglycerides, but a patient should only be prescribed over 3 grams of omega-3 fish oil from a physician due an increased risk of bleeding. (75)

Expected triglyceride lowering effect by omega-3 fish oil: In a meta-analysis that included 21 trials, researchers reported dietary fish oil (omega-3 fatty acids dose range 0.045 to 5.9 grams of EPA and DHA per day) led to a total average decrease in triglycerides of 27 mg/dL, an increase in HDL cholesterol of 1.6 mg/dL, and an increase in LDL cholesterol of 6 mg/dL. Total cholesterol was not affected by fish oil intake. Furthermore the more fish oil consumed, the greater the reduction in triglycerides by a dose-dependent effect. The analysis also determined that patients with a higher triglyceride level prior to starting fish oil experienced a greater response than patients with lower triglycerides. The meta-analysis determined that for every 1 gram of fish oil intake, triglycerides were reduced about 8 mg/dl. Benefits from plant based omega-3 fatty acids (ALA) were inconclusive. (76)

 

Omega-3 fish oil, cholesterol, and mortality:

In a randomized controlled trial called the GISSI-Prevenzione trial done in Italy, 11,324 patients with pre-existing coronary heart disease (CHD) were randomly allocated to either 300 mg vitamin E, 850 mg omega-3 fatty acid ethyl esters (eicosapentaenoic acid [EPA] and docosahexaenoic acid [DHA]), both, or no treatment and followed for 3.5 years noted the following results (78):

A review of 14 randomized clinical trials reported that fish oil is associated with a reduction in total mortality and sudden death, but not nonfatal heart attacks (79).

A 3.5-year study including 11,324 myocardial infarction (MI) survivors with an MI occurring within 3 months) showed that fish oil supplementation at a dose of 1 gram daily, but not vitamin E at a dose of 300 mg daily, significantly reduced the total rate of all-cause mortality, nonfatal MI, and nonfatal stroke (80).

 

Omega-3 fish oil adverse reactions and interactions:

 

Kiwi fruit, HDL, and triglycerides:

Consuming kiwi fruit, rich in vitamins C and E and polyphenols, may be beneficial in cardiovascular disease. A randomized cross-over study found that eating 2-3 kiwi fruit per day for 28 days significantly reduced platelet activation response to collagen and adenosine diphosphate (ADP) by 18% compared to those not eating the fruit. Compared to placebo, kiwi fruit consumption also lowered blood triglycerides levels by 15%. Reduced platelet aggregation and blood triglyceride levels in subjects have been linked with reduced incidence and severity of cardiovascular disease. (86)

A small study on men with high cholesterol who ate 2 kiwi fruit per day for 8 weeks experienced the following (87):

 

Areca-nut is associated with higher triglyceride levels:

Areca-nut chewing has been associated with oral diseases such as oral cancer, oral submucous fibrosis, and periodontal disease.  The areca-nut provides a mild stimulant, causing a warming sensation in the body and slightly heightened alertness.  However, research between 1991 and 2010 shows that chewing areca-nuts is associated with hyperglycemia, type 2 diabetes, metabolic syndrome, obesity, increased body mass, and higher triglyceride levels. (88)

 

Coenzyme Q10 and hyperlipidemia:

For further information about co-enzyme Q10, please see coenzyme Q10 section of Preventive Health Advisor. Although there is no standard for co-enzyme Q10 replacement, and monitoring, we recommend a co-enzyme Q10 supplement with statin medications to keep the level over 0.70 micromol/L, closer to healthy controls. As a guidance for dosing, a trial used co-enzyme Q10 to control blood pressure gradually over months by using doses of 75–360 mg daily to attain a therapeutic level of CoQ10 over 2.0 mcg/ml (89).

 

Coenzyme Q10 and statins:

In a group of 45 patients beginning treatment with 80 mg oral atorvastatin (a statin drug to reduce cholesterol levels), the average concentration of coenzyme Q10 (CoQ10) in the blood decreased within 14 days, and had fallen by approximately 50% after 30 days of treatment. The mean CoQ10 concentration was reduced from 1.26 micrograms per milliliter to 0.62 micrograms per milliliter. Lower CoQ10 levels appear to be a major contributor to muscle pain, exercise intolerance and myoglobinuria (reddish urine associated with the breakdown of skeletal muscle fibers). (90)

Taking statins (atorvastatin, simvastatin, pravastatin), prescribed to lower a person’s cholesterol level, have been demonstrated to lower the amount of coenzyme Q10 (CoQ10) in the blood, in as little as 3 months on standard doses. Forty-two participants being treated for high cholesterol were administered atorvastatin 10 mg (n = 10) and 20 mg (n = 7), simvastatin, 10 mg (n = 5) and 20 mg (n = 10), or pravastatin, 20 mg (n = 5) and 40 mg (n = 5). At the end of the study, these drugs not only inhibited the body’s internal production of cholesterol but also the body’s production of coQ10. (91)

 

Coenzyme Q10, cholesterol, and blood pressure:

Coenzyme Q10 (CoQ10) may be effective in reducing blood pressure and cholesterol. In this study 26 individuals with high blood pressure were supplemented with CoQ10 at a dose of 50 mg twice daily for 10 weeks. At the end of the treatment with CoQ10, CoQ10 levels increased by 0.94 mcg/ml, systolic blood pressure decreased from an average of 164.5 mmHg to 146.7 mmHg, while diastolic blood pressure decreased from an average of 98.1 mmHg to 86.1 mmHg. Average total cholesterol decreased slightly, from 222 mg/dL to 213 mg/dL, while there was no significant change in HDL cholesterol levels (41.1 mg/dL to 43.1 mg/dL). (92)

Yalcin et al. indicated that a relation between low plasma coenzyme Q10 (CoQ10) concentration and coronary artery disease (CAD) exists, and CoQ10 concentrations in patients with CAD was different from healthy individuals (0.41 vs. 0.77 micromol/L, respectively) (15). Additionally, compared to healthy individuals, patients with CAD had a significantly lower ratio of CoQ10 to low density lipoprotein (LDL) cholesterol (p < 0.01) (93).

Based on a review of published studies on coenzyme Q10 (CoQ10) for hypertension researchers found that CoQ10 lowered systolic blood pressure by up to 17 mm Hg and diastolic blood pressure by up to 10 mm Hg. Additionally, CoQ10 doses have increased from 34 mg/day in the early trials to 225 mg/day in the later ones. In a large study, control of blood pressure was achieved gradually over many months and required different doses based on the patient that ranged from 75–360 mg/day to attain a therapeutic blood level of CoQ10 (>2.0  g/ml).  Since absorption of CoQ10 varies with the preparation used and patient response varies, monitoring CoQ10 levels in the blood to guide dosage is desirable. Another factor complicating CoQ10 therapy is the use of statins which are a class of drugs used to lower cholesterol levels. Statins inhibit the synthesis of cholesterol and CoQ10 through the same mechanism. In conclusion, CoQ10 lowers blood pressure and optimal dose can be patient dependent. (89)

 

Coenzyme Q10 and endothelial function:

Endothelial dysfunction occurs after a substance acts upon the endothelium (inner lining) of blood vessels to cause and imbalance of contraction and dilation. Endothelial dysfunction is associated with atherosclerosis, diabetes, hypertension, and cardiovascular disease. A meta-analysis examining the results of five randomized controlled trials, including 194 subjects, found that supplemental coenzyme Q10 (CoQ10) resulted in a clinically significant, 1.7% increase in flow-dependent endothelial-mediated dilation. These findings suggest CoQ10 supplementation is associated with significant endothelia function improvement and provides evidence for use in patients with endothelial dysfunction. (94)

 

Garlic, Allicor, and high cholesterol:

Evidence suggests that a long acting garlic agent may lower high cholesterol. Following 12 weeks of garlic supplementation in a double-blind randomized, placebo-controlled trial, (with 9.6 mg allicin-releasing potential) individuals (n=22) showed a significant reduction in total cholesterol (by -4.2%) and LDL cholesterol (by -6.6%). Corresponding results in the placebo group (n=24) were an increase of 2.0% and 3.7%, respectively. However, HDL cholesterol was significantly improved in the placebo group (by 9.1%) compared to the garlic group (-0.9%). (95)

After 1 year of Allicor treatment, the 10-year absolute risk of IHD was reduced by10.7%, and the 10 year risk of both acute myocardial infarction, and sudden death were reduced 22.7%. A reduction in total cholesterol and LDL cholesterol for men ( by 27.9 and 22.5 mg/dl, respectively) and women (by 11.4 and 10.8 mg/dl, respectively) was reported. Allicor used by women was also reported to prevent age-related cardiovascular risk. (98)

 

Garlic supplementation and hyperlipidemia:

In a review of 29 randomized controlled trials, Garlic in comparison with placebo was associated with a significant reduction in levels of total cholesterol (the difference between the average in the garlic groups and the control groups was -0.19 mmol/L) and triacylglycerol (-0.11 mmol/L). LDL cholesterol lipoprotein and HDL cholesterol were not affected by garlic supplementation. (96)

Compared to placebo, garlic supplementation did not significant change levels of total cholesterol, LDL cholesterol, HDL cholesterol, triglyceride or apolipoprotein B (used to evaluate the risk for cardiovascular disease). This review included 13 randomized controlled trials (n=1,056) with treatment length varying from 12 weeks to 24 weeks. (97)

 

Plant sterol-esters, and how they treat hyperlipidemia:

Plant sterol-esters, chemical name β-sitosterol, are additives to butter, margarine or other spreads with a chemical structure similar to cholesterol, which take the place of cholesterol in the intestines and result in reducing cholesterol absorption (99). When purchasing a spread product for lowering cholesterol, Preventive Health Advisor recommends a product which specifies that it contains at least 8 grams of plant stanol esters, plant sterol esters, or phytosterols per 100 grams of product. Most studies showed a benefit in lowering total cholesterol, LDL cholesterol, and triglycerides. The recommended dose is 2-9 grams of the phytosterols per day which has been taken in studies for 3 weeks to 1 year.

 

Plant sterols, total cholesterol, and LDL cholesterol:

Ayesh et al found a reduction in total and LDL cholesterol of 18% and 23%, respectively, after 21–28 d consumption of 8.6 g plant sterols, provided through margarines in a study of 24 healthy individuals (50% male). No significant changes were observed in the bacteria in the stomach/intestine, nor where their changes to female sex hormone levels. Overall plant sterols were well tolerated. (100)

Daily consumption of  20 g spread enriched with 1.6 g plant sterols, naturally occurrence substances, was observed to have a cholesterol-lowering effect in a 1-year double-blind, placebo-controlled trial of 185 individuals with normal or slightly elevated cholesterol levels. Total cholesterol was significantly reduced on average by 4% and LDL cholesterol on average by 6%. Plant sterol concentrations in the blood were significantly increased from 2.76 to 5.31 ( micromol/mmol total cholesterol) for campesterol and from 1.86 to 2.47 for beta-sitosterol. To obtain adequate plant stanols for lowering cholesterol, a greater chance of benefit is possible with a stanol margarine which states that it contains 8 grams of plant sterol or plant stanol per 100 grams of product. (101)

Plant stanol esters, naturally occurring substance, are associated with a cholesterol-lowering effect of about 10% for total cholesterol and 15% for LDL cholesterol. In contrast, stanol ester margarine at 2-3 g/d stanols are associated with a reduction in total and LDL cholesterol of 15% and 20%, respectively. Stanol ester margarine can be a dietary treatment for those with high cholesterol levels. (102)

Plant sterols did not show a benefit to LDL cholesterol in all trials: Researchers studied oral plant sterol-esters at a dose of 3, 6, and 9 g/day plant sterol-esters, naturally occurring unsaturated fatty acids, in low-fat dressings and spreads in a 8-week parallel study of 84 individuals. No significant changes in LDL cholesterol were seen compared with controls. However, the ratio of total cholesterol to HDL cholesterol was significantly lower among those consuming 9 g/day plant sterols compared to controls (-9.6% vs. 2.6%). Blood levels of fat-soluble vitamins remained normal during the entire study. The change in the level of triglycerides in the group taking 3 g plant sterols/day was significantly different when compared to the control group (median: -13.3% vs 7.8%). Overall plant sterol-esters were well tolerated. (103)

 

Policosanol and hyperlipidemia:

Policosanol and high cholesterol: Policosanol is a natural extract of plant waxes derived from sugar cane which is effective for hyperlipidemia, and has an excellent safety profile .

Policosanol, 5 or 10 mg/day administered along with omega-3 FA 1 g/day improved total cholesterol, LDL cholesterol, HDL cholesterol, and triglycerides in patients suffering from type II hypercholesterolemia (high cholesterol). After 8 weeks on omega-3 FA + policosanol 5 and 10 mg/day or omega-3 FA + placebo, participants taking policosanol experienced a 21.1% and 24.4% reduction in LDL-C for the 5mg and 10mg doses respectively. Total cholesterol was significantly reduced by 12.7% and 15.3% in participants taking policosanol 5mg and 10 mg, respectively. HDL-C was significantly increased by 14.4% and 15.5% in participants taking policosanol 5mg and 10 mg, respectively. Triglycerides was significantly reduced by 13.6% and 14.7% in participants taking policosanol 5mg and 10 mg, respectively. Placebo experience a reduction in triglycerides of 14.2% but reported no effect on total cholesterol, LDL-C, or HDL-C. (104)

 

Comparison of policosanol to plant sterols:

A meta-analysis concluded that policosanol, a natural extract of plant waxes, is a promising alternative to standard lipid-lowering agents for those suffering from high cholesterol. The researchers limited their analysis to randomized, double-blind, placebo-controlled trials (23 plant sterol/stanol trials and 29 policosanol trials). The results showed that both plant sterol/stanol and policosanol had beneficial effects on blood lipid levels, but on the whole, policosanol was significantly better. Compared to plant sterol/stanol treatment (3.4 g/day), policosanol treatment (12 mg/day) caused larger decreases in total cholesterol (-16% vs. –8%), LDL cholesterol (-24% vs. –11%), triglycerides ( 12% vs. +4%) and LDL:HDL ratio (-33% vs. -12%) and resulted in a larger increase in HDL cholesterol (+11% vs. 0%). Plant sterols/stanols and policosanol were both well tolerated with hardly any adverse side effects. (105)

 

Policosanol Adverse Reactions and Interactions:

 

Vitamin D, hyperlipidemia, and diabetes mellitus:

Maintain favorable levels of vitamin D in all patients with not only hyperlipidemia, but in all patients with any risk factors for cardiovascular disease. Vitamin D is not established as a direct cause of cardiovascular disease, but vitamin D deficiency is associated with a higher incidence of hypertension, hyperlipidemia, coronary artery disease, stroke, chronic kidney disease, and diabetes mellitus type 2 (109). A retrospective analysis showed that patients with diabetes mellitus have a very low 25-hydroxy vitamin D level, and also found that high levels of triglycerides, LDL cholesterol, and HbA1C had a consistent association with vitamin D deficiency in type 2 diabetes patients (110). Please see the section on vitamin D for further information.

 

Green tea and hyperlipidemia:

Green tea is rich in the class of antioxidant polyphenol compounds known as catechins. Green tea has numerous health benefits cited in research. Green tea has been consumed for centuries by Asian countries and has been cited as generally safe, but adverse reports of the use of green tea has been reported. Green tea has been quoted by multiple sources to contain a range of 120 to 160 mg of catechins per cup and an average of 23 mg of caffeine per cup (range of 11-48mg) but with high variability. Preventive Health Advisor recommends that liver function tests be obtained for green tea consumption of 4 cups per day or greater at baseline, after 3 months, at 6 months, and then at the physician’s discretion due to high a variability in green tea catechin content. Green tea extract is not recommended due to increased risk of hepatotoxicity with a higher concentration of catechins which it provides. Patients should be advised to avoid drugs metabolized by the liver such as acetaminophen.

 

Multiple trial outcomes, green tea, and hyperlipidemia:

A systematic review and meta-analysis of randomized, controlled trial evaluated the relationship between green tea catechins and serum lipid levels (including total, LDL and HDL cholesterol levels and triglycerides), 20 trials, including a total of 1,415 subjects were included in the analysis. Green tea catechins in doses ranging from 145 to 3,000 mg/d taken for 3-24 weeks were found to reduce total cholesterol by 5.46 mg/dL and LDL cholesterol by 5.30 mg/dL, as compared to controls. No significant changes in HDL cholesterol or triglycerides were found. (111)

In a review and meta-analysis of studies investigating the effects of green tea and its extract (catechin with antioxidant properties) on total cholesterol, LDL cholesterol, and HDL cholesterol, results of 14 randomized, controlled trials involving 1,136 subjects were analyzed and results showed that consumption of green tea was associated with significant reductions in total cholesterol concentration (by 7.20 mg/dL) and LDL cholesterol concentration (by 2.19 mg/dL). No significant change in HDL cholesterol was found. These results suggest that consumption of green tea or green tea extract may exert beneficial effects on cholesterol levels. (112)

A beneficial effect of green tea (Camellia sinensis) taken as 250mg capsules daily was demonstrated, with a significant reduction of total cholesterol and LDL cholesterol levels in an 8-week double-blind crossover study of 33 patients 21-71 years of age with dyslipidemias or an abnormal amount of lipids in the blood. Green tea supplementation resulted in a 3.9% reduction (p = 0.006) in total cholesterol concentrations and a 4.5% reduction (p = 0.026) in LDL cholesterol. The intake of green tea did not significantly influence HDL cholesterol, triglyceride, and Apo-B levels. (113)

Daily supplementation with 379 mg of green tea extract (GTE) was found to be associated with beneficial effects on blood pressure, insulin resistance, inflammation and oxidative stress, and cholesterol in 56 patients with obesity-related hypertension. At the end of the 3-month study both systolic and diastolic blood pressures significantly decreased in the GTE group when compared to the placebo group (p < .01). Additionally, compared to the placebo group, significant (p < .01) reductions in glucose and insulin levels and insulin resistance were observed in the GTE group. Serum tumor necrosis factor α and C-reactive protein were significantly lower, whereas total antioxidant status increased in the GTE group compared with the placebo (p < .05). Supplementation also contributed to statistically significant decreases in the total cholesterol, LDL cholesterol and triglycerides. There was also an increase in HDL cholesterol observed. Following 3 months of treatment, systolic blood pressure dropped about 4 mmHg and diastolic bp dropped about 2 mmHg on average. LDL improved from 3.5 to 3.1 mmol/L, HDL from 1.2 to 1.4 mmol/L, triglycerides 1.4 to 1.1 mmol/L, total cholesterol 5.4 to 5.0 mmol/L, C-reactive protein from 3.4 to 2.5 mg/L and tumor necrosis factor 5.4 to 4.7 ng/L. (114)

A randomized double-blind, controlled parallel multi-center trial consisting of a 2-week run-in period and a 12-week treatment period was conducted to investigate the effects of green tea extract (GTE) high in catechins on body fat reduction and reduction in the risks for cardiovascular disease in obese individuals. Data consisted of 240 subjects 25 to 55 years of age (catechin group; n = 123, control group; n = 117). Participants in the treatment group had an intake of 583 mg catechin (equivalent of about 4-5 cups of green tea), while those in the control group had an intake of 96 mg catechin. Decreases in body weight, body mass index, body fat ratio, body fat mass, waist circumference, hip circumference, visceral fat area, and subcutaneous fat area were found to be greater in the catechin group than in the control group. Those in the treatment group experienced a loss of about 4 pounds after 12 weeks. A greater decrease in systolic blood pressure (SBP) was found in the catechin group compared with the control group for subjects whose initial SBP was 130 mm Hg or higher.  A reduction of 9.0 mm Hg vs 2.9 mm Hg was seen. Low-density lipoprotein (LDL) cholesterol was also decreased to a greater extent in the catechin group. No adverse effect was found. In conclusion, catechins, especially in high amounts, reduce body fat, cholesterol levels, and blood pressure in women and men. (115)

 

Green tea interactions and adverse reactions:

While drinking green tea, patients should be advised to avoid drugs metabolized by the liver such as acetaminophen.

According to Schönthal, the following adverse reactions have been reported (116):

Green tea contains caffeine which is generally recognized as safe by the FDA and AMA but can be dangerous with adverse effects such as high bp, stroke, and arrythmias reported. If more than 4 cups of caffeinated beverages are consumed per day, it is prudent to seek physician and/or pharmacist approval of caffeine consumption with any medications or supplements.

When green tea is consumed in the form of whole leaves, or if it is steeped long enough to contain tannins, vitamin K is generally present in amounts significant enough to counteract the effects of warfarin (117,118), but if green tea is steeped for a short time, and the leaves are not consumed, green tea has very low concentrations of vitamin K (182).

Caution use of whole green tea leaves or powder in patients taking warfarin which may make achievement of therapeutic PTINR difficult. Vitamin K levels in coffee and tea was performed which revealed that vitamin K concentrations were about 0.03 μg/100 mL or less, and according to this source, brewed tea or coffee contains extremely small amounts of vitamin K and is not a dietary source (119).

Consumption of green tea at a dose of 4-6 cups daily for 6 months (480-960 mg of green tea catechins) has resulted in occasional episodes of toxic hepatitis, and the risk appeared to increase with chronic use (120). Caution use of green tea in patients with other forms of hepatitis, liver dysfunction, use of other medications cleared by the liver such as acetaminophen.

No adverse effect of green tea was found in a 12 week RCT but the study was fairly short term and both the study group and the control group had a low incidence of elevated liver function tests (115).

 

Cocoa and hyperlipidema:

Cocoa and chocolate contains caffeine and theobromine. Caffeine intake up to 300 mg per day is generally safe for healthy adults. Each standard sized milk chocolate bar such as Hershey’s contains about 10 mg of caffeine, and each standard size dark chocolate bar contains about 31 mg of caffeine. Standard caffeine intake is generally recognized as safe by the FDA and AMA but can be dangerous with adverse effects such as high bp, stroke, and arrythmias reported. Cocoa and chocolate also contains theobromine which is known to act as a heart stimulant, vasodilator, and diuretic which may be responsible for some of the therapeutic action of cocoa (138). Theobromine in cocoa may intensify the blood pressure lowering effects of any blood pressure medications.

Cocoa and milk may help improve LDL and HDL. In a study, scientists recruited 42 volunteers (19 men, 23 women) with a mean age of 70 to participate in a randomized trial. All the participants received 500 mL of skimmed milk/day with or without 40 grams of cocoa powder for 4 weeks. Cocoa powder contains polyphenol, which acts as an antioxidant protecting cells against damage. At the end of the study the researchers found that milk plus cocoa was associated with an increase in HDL cholesterol levels by 2.67 mg/dL, compared to only milk. In addition, cocoa plus milk was associated with a reduction in oxidized LDL cholesterol levels by 12.3 U/L compared to milk only. In conclusion, the authors suggest that a combination of cocoa and skimmed milk may beneficially affect cholesterol levels in the blood. (121)

Cocoa and the lipid profile: Eating cocoa could help reduce LDL cholesterol, according a 4-week study conducted by Baba and colleagues in which 160 adults with either normal or raised cholesterol levels were randomly assigned to receive either a daily placebo compound or a high-polyphenol cocoa powder. Three different levels of cocoa powder were tested all consumed as a beverage after the addition of hot water, twice each day: 13g, 19.5g or 26g per day. In all the cocoa groups, blood levels of LDL cholesterol decreased significantly compared with levels seen at the beginning of the study. Subjects with clinically raised cholesterol levels seem to benefit specifically from the cocoa supplementation, in that LDL cholesterol levels fell, while levels of HDL cholesterol rose.  Specifically, among subjects administered the high dose cocoa total cholesterol, LDL, and triglycerides decreased by 1.15%, 3.77%, and 5.11%, respectively. HDL increased by 9.52%. In addition, there was less oxidation of the LDL cholesterol, a process that is believed to drive the early stages of heart disease. It is believed that cocoa is rich in polyphenol antioxidants that are believed to help protect cells from oxidation and may improve blood pressure control. (122)

 

Flaxseed and cholesterol levels:

Flaxseed, the prostate, and total cholesterol: A pilot study suggests that a low-fat, flaxseed-supplemented diet decreases prostate-specific antigen (PSA) and cholesterol levels as well as benign prostatic epithelial cell proliferation. Fifteen men who were scheduled to undergo repeat prostate biopsy were instructed to follow a low-fat (less than 20% kcal), flaxseed-supplemented (30 g/day) diet for 6-months. At the end of the study period, significant decreases in PSA (8.47 to 5.72 ng/mL; P = 0.0002) and total cholesterol (241.1 to 213.3 mg/dL; P = 0.012) were seen. Significant change was not observed in total testosterone. A significant decrease in proliferation rates in the benign epithelium from 0.022 to 0.007 (P = 0.0168) was observed. (123)

A total of 161 men diagnosed with prostate cancer and scheduled at least 21 days before prostatectomy were randomized into 4 groups – control (usual diet), flaxseed-supplemented (30gm/day), low-fat diet (<20% of energy from dietary fat), or flaxseed-supplemented plus low fat. In addition to signs of lower tumor proliferation, men in the low-fat diet group had significant reductions in body mass index and total and low-density lipoprotein cholesterol (p= 0.048).(124)

 

Sodium bicarbonate and hyperlipidemia:

Sodium bicarbonate, total cholesterol and LDL cholesterol: Sodium bicarbonate water may improve total cholesterol, LDL cholesterol, and possibly systolic blood pressure. The mechanism of this benefit is believed to be an increase in gastrointestinal pH which reduces secretion of digestive enzymes dependent on a lower pH, and therefore, a reduction of fatty acid and cholesterol absorption may occur (125). Traditional medicine has taught that sodium should be limited to 2 grams per day in patients with hypertension since excess sodium will increase blood pressure. Sodium content of ¾ teaspoon of sodium bicarbonate is about 900 mg, and if this therapy is used by a patient, closer adherence to lowering sodium intake is important.

A study examined the effects of drinking sodium-bicarbonated mineral water on cardiovascular risk among 18 young volunteers in two 8-week intervention periods. In addition to their normal diet, participants took 1 L/day control low mineral water, followed by 1 L/day bicarbonate water which was the equivalent of ¾ teaspoon of sodium bicarbonate in 1 quart of water. Results indicate that dietary intake, body weight and body mass index were not significantly affected. However, systolic blood pressure decreased significantly after 4 weeks of bicarbonated water consumption, though no significant differences between Weeks 4 and 8 were demonstrated. Consumption of bicarbonated water was shown to significantly reduce total cholesterol by 6.3% and reduced LDL (bad) cholesterol by 10%. This study suggests that supplementing dietary intake with bicarbonate water may reduce cardiovascular risk. (125)

A study focused on a group of postmenopausal women drinking sodium-rich carbonated mineral water. Women included in the study were amenorrheic (the absence of menstrual periods) for more than a year, healthy, and not obese (body mass index [BMI] < 30 kg/m2). The study consisted of 2 intervention periods of 2 months each, during which women drank 1 L/d of a control mineral water (low mineral content) for 2 months followed by the carbonated mineral water, rich in sodium, bicarbonate, and chloride, for remaining 2 month. Measures including body weight, height, blood pressure, and BMI were measured. Blood samples were taken and analyzed.  Results indicate that drinking sparkling mineral water significantly reduced total cholesterol by 6.8% and reduced low-density lipoprotein (LDL) cholesterol, the so-called “bad” cholesterol, by 14.8% and increase the good high-density lipoprotein (HDL) cholesterol by 8.7%. Blood pressure levels did not change throughout the study. Results suggest that bicarbonate from mineral waters may reduce cardiovascular risk in healthy postmenopausal women. (126)

 

Kale and cholesterol levels:

Thirty-two men, all with cholesterol levels above 200 mg/dL, were given 150 mL of kale juice per day for 12 weeks. Blood tests at the end of the study period showed a 27% increase in levels of HDL cholesterol, and a 10% decrease in levels of LDL cholesterol and in arterial plaque formation. In addition, the researchers reported the kale juice provided significant boosts to the levels of glutathione peroxidase and selenium, two high-powered antioxidants. Regular addition of kale juice to the diet, say the researchers, may be advisable to reduce risk of coronary artery disease. (127)

 

Broccoli sprouts and hyperlipidemia:

Broccoli sprouts may be produced by anyone at home in a Mason jar. They appear to have numerous potential health benefits and are an inexpensive way to add nutrition to the diet. Research is currently being conducted in a variety of potential treatments but is in early stages. Type 2 diabetes patients who received placebo, broccoli sprouts powder, 5 grams daily or 10 grams daily,  for 4 weeks showed the following results (129): Total cholesterol decreased 6.9%, 13.6%, and 10.1% respectively. LDL lowered by 3%, 14.9% and 10.5% respectively. HDL decreased by 13.9%, 13%,  and 4.6% respectively. Triglycerides lowered by 6.9%, 7.2% and 18.7% respectively. Fasting blood sugar reduced by 1%, 13.1% and 19.3% respectively. Please see the broccoli sprouts section for further information.

 

Resveratrol in hyperlipidemia and heart disease:

For further information, interactions, and adverse reactions of resveratrol: See resveratrol in Preventive Health Advisor. Resveratrol has been promoted as an inhibitor of platelet activation and anti-inflammatory believed to have potential benefits for heart health in in-vitro and in animal studies. This agent requires more research for confirmation in humans, and should be avoided until further research has been completed. Paradoxically, resveratrol promoted atherosclerosis in hypercholesterolemic rabbits compared to a control group (128). Resveratrol-treated rabbits had an increase in atherosclerotic lesions (p<0.002), which suggested that resveratrol results in atherosclerotic development, rather than protecting against it. (128)

 

Red yeast rice and cholesterol:

Red yeast rice, made by fermenting a type of red yeast called Monascus purpureus over rice, contains Monacolin K which is chemically similar to lovastatin, a prescription drug used to treat high cholesterol. In the US, the Food and Drug Administration banned the sale of red yeast supplements containing lovastatin as over-the-counter supplements. Only red yeast supplements without Monacolin K were made available without a prescription. However, dietary supplements are not highly regulated and a review of 12 common brands of red yeast revealed the quantity of Monacolin K varied from 0.10 mg to 10.09 mg per capsule. (130) Red yeast rice is often used to lower cholesterol and tryglycerides. Unfortunately, red yeast rice products have been found to contain citrinin, a toxic by-product of the fermentation process.

Noting that many patients don’t take their cholesterol-lowering statins (a class of drugs used to lower cholesterol) because of side effects like muscle pain, researchers gave 18 subjects with high cholesterol an all-natural, cholesterol-lowering powdered shake (with almond, soy or low-fat milk) that contained 1,200 mg of red yeast rice and 1,250 mg of phytosterols. After six weeks of drinking the shake twice a day, total cholesterol dropped by an average of 19% and LDL cholesterol by 33%. Other measures such as body mass index, triglyceride, HDL cholesterol levels, or systolic and diastolic blood pressure did not change significantly. (131)

 

Red yeast rice vs. statin medication:

A randomized, double-blind trial compared the tolerability of red yeast rice with that of a statin drug (cholesterol lowering medications) in a population with statin-associated myalgia (ie, muscle pain, stiffness or cramps). A total of 43 adults with dyslipidemia (abnormal amount of cholesterol and/or fat in the blood) and a history of statin discontinuation due to myalgia were included. All patients were randomly assigned to either red yeast rice 4800 mg daily, taken as 4 x 600-mg capsules twice daily (Sylvan Bioproducts, Kittanning, PA) available at GNC, or pravastatin 20 mg twice daily. All participants were concurrently enrolled in a therapeutic lifestyle change program. After 12 weeks, both treatments were associated with a low incidence of treatment discontinuation due to myalgia, no evidence of muscle weakness, and a similar level of LDL cholesterol reduction. Mean LDL-C level decreased 30% in the red yeast rice group and 27% in the pravastatin group. Withdrawal due to myalgia was 5% in the red yeast rice group and 9% in the pravastatin group (p = 0.99). Hip flexor muscle strength did not differ between the 2 groups at week 4 (p =0.61), week 8 (p= 0.81), or week 12 (p= 0.82). This study shows that red yeast rice lowers LDL-cholesterol and may be better tolerated than pravastatin. (132)

 

Combination of natural agents vs. placebo for high cholesterol:

Eighty elderly subjects over the age of 75 with high cholesterol were evaluated after taking red yeast rice. The subjects received either a placebo or a pill containing 500 mg of berberine, 10 mg of policosanol, 200 mg of red yeast rice, 0.2 mg of folic acid, 2 mg of CoQ10, and 0.5 mg of astaxanthin. Policosanol, a compound derived from sugar cane, has been shown to enhance healthy cholesterol metabolism. Berberine is derived from various plants used for immune and cardiovascular support. The subjects were assessed for lipid levels at the beginning of the study and again after 3, 6, and 12 months of supplementation. The results of the study showed that the supplement group showed a 20% improvement in total cholesterol, a 31% improvement in LDL cholesterol, and a 10% improvement in insulin resistance. No change was seen in HDL. The study also demonstrated that safety, tolerability, and compliance were high. (133)

 

Red yeast rice adverse reactions and interactions:

A dangerous toxin has been found in red yeast rice supplements. Citrinin is a potential cancer causing toxin found in a concentration of 0.2 to 17.1 micrograms per gram in all of the commercially produced samples of red yeast rice extract tested in a study by Sabater-Vilar M. et al. A standardized method of lab testing for cancer producing toxins was performed with the citrinin found. A dose dependent mutagenic response was noted to occur from citrinin. (134)

There are serious concerns about reliable purity and standardization of red yeast rice extract supplements. The total amount of active ingredients varied from 0% to 0.58%. Only 1 out of 9 brands had the full spectrum of active compounds. Citrinin is a mutagenic toxin was found to be present in 7 of the 9 preparations. (135)

 

Spirulina and cholesterol:

Spirulina is a type of blue-green algae that is rich in protein, vitamins, minerals, and carotenoids, antioxidants that can help protect cells from damage. It contains nutrients, including B complex vitamins, beta-carotene, vitamin E, manganese, zinc, copper, iron, selenium, and gamma linolenic acid (an essential fatty acid). As cited by Karkos P.D, et al, spirulina at a dose of 4.2 g daily given to 15 male volunteers revealed no significant increase in high-density lipoprotein (HDL) levels, but researchers observed a significant reduction of low-density lipoprotein (LDL) cholesterol after 8 weeks of treatment (136).  More research including efficacy and safety data is required before this agent can be recommended routinely since a number of spirulina samples have been found to be contaminated with a neurotoxin, anatoxin-a (136).

 

 

Summary: Hyperlipidemia, Dyslipidemia, High Cholesterol and Triglycerides

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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