What's better for lowering cholesterol: butter and bacon or a lifetime prescription for a statin drug like Lipitor? Low-carb proselytizers say you can clear your arteries with massive amounts of protein, even as drug companies are peddling medication to everyone who needs it and some who may not. But there's a third option, a natural plan that can reduce your risk of heart disease without subjecting your body to the stresses of fad diets or powerful drugs.
HDL "good"; LDL "bad"
First, not all cholesterol is harmful. When most people talk about cholesterol, they're thinking about low-density lipoprotein, which threatens to create plaque buildup in your arteries. The more LDL builds up (a condition called atherosclerosis), the narrower the passage pumping blood to the body and the harder the heart has to work to keep circulation flowing. To make matters worse, bits of the plaque can rupture and cause clots or even a heart attack.
High-density lipoprotein, on the other hand, is "good" cholesterol. HDL keeps an inventory of LDL levels and clears out extra stock. Ideally, you want to keep your LDL low and HDL high. But when it comes to finding the right ratio for you, the picture gets fuzzy.
Genetics plays a role in determining cholesterol levels, as does a handful of other factors. Losing any excess weight usually helps, though some individuals may have high cholesterol despite a healthy weight and lifestyle. And while women tend to have higher HDL levels, that doesn't necessarily protect them against developing heart disease, according to a University of Alabama study.
weighing in
About 105 million Americans age 20 and borderline high-risk levels of total cholesterol, defined as 200 mg/dL other 42 million or so have high-risk levels of 240 mg/dL or more.
Can we blame this national health problem on obesity? Yes and no, says Robert H. Eckel, M.D., chairman of the American Heart Association's Council on Nutrition, Physical Activity and Metabolism. Extra pounds do increase LDL and decrease HDL. But Eckel adds that emerging research has turned many of our assumptions about cholesterol upside down. "Weight change doesn't affect LDL very much," he explains. "It's more the composition of the diet. Diets rich in saturated fats, trans fats and dietary cholesterol predict higher LDL levels, while those restricted in these kinds of fats lower them."
the low-carb debate
Low-carb dieting, which can boost saturated fat and dietary cholesterol, recently made headlines as a way of helping people raise their good HDL, a benefit attributed to sustained weight loss--though it may simply be the body's natural response to a diet higher in fat as it now has more to clear from the bloodstream.
"The effect of low-carb diets depends on the types of fats that are ingested and how much weight loss occurs," says Eckel. "Saturated fats may raise HDL, but diets high in saturated fat are associated with more heart disease. The story is more complex than it appears."
The impact of low-carb eating on bad cholesterol is also complex: LDL can rise, fall, or drop and then rebound. Yet any reductions are "minimal, despite the weight loss that may be achieved," says Lona Sandon, R.D., a spokeswoman for the American Dietetic Association. "The missing point is that high cholesterol is not the only thing that leads to heart disease. High levels of homocysteine, C-reactive protein and other markers have been shown to worsen on these types of diets, too. [See "Other Signs of Danger" right.] Many people with normal cholesterol levels have heart attacks and are likely to have high levels of these inflammatory markers."
The American Heart Association continues to promote a diet that is rich in fruits and vegetables, whole grains, fiber and fish, Eckel notes. "This type of diet has historically been associated with less heart disease, stroke, cancer and diabetes. The long-term use of most of the high-protein diets raises concerns about nutritional deficiencies that may reduce protection."
the high-carb debate
So is it back to carbohydrates we go? That depends. Diets high in complex carbs (i.e., fruits, vegetables, nuts, seeds and unrefined grains) can lower total cholesterol, LDL and triglyceride levels and supply the body with essential vitamins and minerals, says Sandon. It's the simple carbs in snack foods and sugary beverages that supply the body with so many extra calories. And yet, adds Eckel, neither simple nor complex carbs by themselves seem to adversely affect LDL.
That brings us back to fat. A study in the American Journal of Clinical Nutrition found that a low-fat, high-carb diet reduced total, LDL and HDL cholesterol without modifying the ratio or raising triglycerides. In a related study at Laval University in Quebec City, Canada, researchers found that adding monounsaturated fatty acids (e.g., olive oil) to such a diet slowed HDL loss from 10 percent to 3 percent. And both drops may be simply the body's reaction to having less LDL to clear away.
praise for plants
A new study indicates that combining cholesterol-lowering foods (almonds, soy protein, plant-sterol margarine) with high-soluble fiber foods (oats, barley, fruits, vegetables) significantly reduces the risk of heart disease. University of Toronto scientists looked at three diets in people with high cholesterol: low saturated fat, low saturated fat with a statin medication, and the Portfolio Diet (see above), a plant-based strategy that draws on advice from the AHA and the National Cholesterol Education Program. The patients following a simple low-fat diet saw only modest results, but those following the Portfolio Diet fared as well as the patients on medication, and reduced their LDL levels by up to 30 percent.
Working out has a similar effect. In a study in the New England Journal of Medicine, researchers found that low-fat diets lowered HDL but low-fat diets combined with exercise increased HDL. The report noted that weight lost from dieting alone is usually muscle mass, while weight lost through diet and exercise is mostly fat.
hit the walnuts
Perhaps the most surprising element in the Portfolio Diet is the nuts, yet their many calories come from healthy monounsaturated fat. When study subjects received 20 percent of their calories from walnuts, LDL was lowered by more than 16 percent after four weeks, according to a report in the New England Journal of Medicine. Other foods with anti-cholesterol power include good-fat-rich salmon and avocados. And researchers at the Helsinki University Central Hospital found that adding plant sterols to a low-fat diet boosted total cholesterol reduction from 3 percent to 8 percent and LDL reduction from 5 percent to 13 percent.
Federal guidelines suggest keeping cholesterol consumption under 300 milligrams per day, but that doesn't mean you can never again eat an egg (about 210 mg cholesterol). Look at your overall dietary budget, and figure out where your cholesterol is coming from, says Alice H. Lichtenstein, D.Sc., director of the cardiovascular nutrition laboratory at Tufts University in Boston. For example, spreading trans-fat-free margarine with cholesterol-binding plant sterols on your toast instead of fat-filled butter one morning may give you the leeway to enjoy two eggs scrambled the next.
Finally, switching from one or two large meals a day to five or six smaller ones can lower cholesterol by about 5 percent, according to researchers at the University of Cambridge in England. The results occurred even when subjects ingested more calories.
drug therapy
Drugs may be required to bring down dangerously high cholesterol that can't be controlled by diet and exercise alone. The most commonly prescribed medications are the statins (Lipitor, Pravachol, Zocor), which obstruct an enzyme necessary for producing cholesterol. Statins can slash blood-fat counts by as much as 60 percent in just a few months. New NCEP recommendations, issued in July, call for high-risk heart or diabetes patients to medicate when their LDL is 100 or above, while those at moderate risk get the same advice at 130 or above.
But the drugs used to control cholesterol--statins, along with resins, gemfibrozil and clofibrate--can lead to muscle weakness, pain and liver toxicity. "People taking statins should have a liver-enzyme check regularly," says Jane Guiltinan, N.D., director of the Bastyr University Center for Women's Wellness in Kenmore, Wash.
Diet and exercise should always be tried first to manage cholesterol, says Guiltinan. "If this is unsuccessful after six months or so, then more aggressive intervention is warranted."
alternative approaches
Along with better nutrition and working out, Guiltinan suggests these natural alternatives that may help control blood fats:
