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The numbers are changing — that is, the cholesterol numbers. And with those changes come new approaches to lowering cholesterol and keeping it low for patients with heart disease and diabetes.
Last May, the Bethesda, MD-based National Heart, Lung, and Blood Institutes’ National Cholesterol Education Program (NCEP) revised its cholesterol guidelines downward to protect patients against heart disease. In the first changes in more than a decade, NCEP recommended:
Specifically, the guidelines say clinicians should treat more aggressively for heart disease, particularly patients with Type 2 diabetes who are at high risk of dying from a heart attack.
NCEP defines low HDL as below 40 mg/dL; previously the low HDL range began at 35 mg/dL. The change reflects new findings about the significance of low HDL and the strong link between low HDL and an increased risk of heart disease. An HDL of 60 mg/dL is considered cardioprotective. Although LDL guidelines are less specific and are tailored to several variables, NCEP officials say a good guideline is LDL lower than 130 mg/dL and HDL higher than 40 mg/dL.
The guidelines also offer dietary guidelines that include less than 7% of calories from saturated fat and less and 200 mg of dietary cholesterol. It also allows up to 35% mg/day of daily calories from fat, provided most is from unsaturated fat, which does not raise cholesterol levels. The guidelines also encourage the use of foods that contain plant stanols and sterols or are rich in soluble fiber, including certain margarines and salad dressings and foods high in soluble fiber, including cereal grains, beans, peas, legumes, and many fruits and vegetables.
Recent figures show that at least 51.9% of all adults, or 98 million Americans, are at intermediate or high risk of heart disease due to blood cholesterol levels higher than 200 mg/dL.
"Lowering LDL cholesterol while raising HDL at the same time often has proved to be difficult, but new research shows there are several natural ways of achieving just that, without the side effects that have been associated with many prescription cholesterol-lowering drugs," says nutrition researcher David Kritchevsky, PhD, a professor at Wistar Institute in Philadelphia.
Several specific foods have been found to have cholesterol-lowering effects:
• Apples. One a day really could keep the cardiologist away. Recent research at the University of California at Davis shows that apple juice and whole apples inhibit LDL oxidation by 9-34% in laboratory studies.1 Researchers suggest the effect is caused by the presence of several classes of phenolic compounds: cinnamates, anthocyanins, flavan-3-ols, and flavonols that prevent platelet aggregation and help keep LDL from forming artery-clogging plaque. Finally, apples are a rich source of d-glucaric acid, an enzyme-inducing agent that may slow the formation of LDL.
• Oatmeal. Yes, there’s some truth to those television commercials touting the cholesterol-lowering properties of oatmeal. "The primary mechanism seems to come from the 3 g per serving of oat-soluble fiber, beta-glucan, that acts like a sponge in the intestines, soaking up fats before they reach the bloodstream," says David Katz, MD, a specialist in preventive medicine at Yale University Medical School in New Haven, CT.
Katz also suggests that the fiber in oats helps prevent blood vessel constriction by slowing absorption of fats and carbohydrates into the bloodstream.
The value of oats in cholesterol control was recognized in 1997 when the U.S. Food and Drug Administration (FDA) approved labeling claims that consuming oatmeal, oat bran, or whole oat flour might help reduce the risk of heart disease — the first time the FDA allowed a health claim for a specific food. The decision was made after reviewing 37 clinical studies regarding the health benefits of oatmeal and oat bran.
In a study presented to the American College of Nutrition in 1999, Katz showed that healthy subjects who ate a high-fat meal that included oatmeal or 800 IU of vitamin E maintained their pre-meal blood vessel diameter, while controls experience a 13.4% constriction in blood flow.
• Hamburgers and milkshakes. Well, soy burgers and soy shakes, anyway. Although the health benefits of soy have been hotly debated, a study at Wake Forest University shows that 25 g/day of soy isoflavones adds fiber to the diet — 2 g in each 4-ounce serving — and lowered total cholesterol by 4% and LDL by 6% in patients with LDL levels ranging between 140 and 200 mg/dL.2
Interestingly, patients at the higher end of the range received the greatest benefits, lowering their total cholesterol by 8% and LDL by 10%.
"Soy’s plant proteins help cut the formation of LDL in the liver, and there have been some suggestions that soy isoflavone intake can help raise HDL," says John R. Crouse, MD, professor of medicine at Wake Forest University in Winston-Salem, NC.
Beyond the usual recommendation for antioxidants like vitamins C and E to help reduce ather-osclerosis, there is some intriguing evidence for the effectiveness of these lesser-known natural supplements:
• Artichoke extract. A new German study shows that patients with high total cholesterol —higher than 280 mg/dL — who took 1,800 mg supplements daily containing dry artichoke extract for six weeks lowered their LDL by more than 22.9%, while their total cholesterol dropped by 18.5%. At the same time, their LDL:HDL ratio decrease by 20.2%, all without adverse events.3 Artichokes contain cynarin, a compound in the leaves, roots, and flower heads of the spiny plant that increases the flow of bile from the gall bladder, helping excrete excess cholesterol from the body.
• Phytosterol foods and pills. Margarine fortified with phytosterols such as Benecol and Take Control have been shown to cut artery-clogging LDL cholesterol by 10-14%, dropping heart attack risk by 20% or more. However, the shortcoming of this method is that eating the recommended amounts of these heart-healthy spreads adds as much as 240 calories to the daily diet. The same cholesterol-blocking phytosterols used in those margarine spreads are available as supplements that contain virtually no calories.
Phytosterols have been studied extensively since the late 1940s. Research in the 1950s and 1960s demonstrated cholesterol lowering of approximately 10% when phytosterols are consumed with meals. More recently, 12 subjects were given 740 mg of phytosterol from soybeans daily for four weeks. Total cholesterol declined 10%; the LDL was reduced by 15%. And the ratio of total cholesterol to HDL cholesterol, which was not affected, rose 25%.
"We’ve known for more than 40 years that if one takes enough concentrated plant sterols along with a meal, then most of the cholesterol in the food consumed at the same meal won’t be absorbed," says Kritchevsky, who pioneered phytosterol research. Phytosterols work by binding with cholesterol, ushering it through the digestive system, and excreting it before it has a chance to be absorbed into the bloodstream and form plaque.
• Alfalfa and yucca supplements. Compounds called saponins, naturally found in alfalfa and yucca plants, haven’t been studied much in humans, but their cholesterol-lowering properties are becoming apparent. European animal research suggests alfalfa saponins can lower LDL by 50% — and may even reverse the artery-clogging process by literally scouring out fatty deposits in blood vessels. "Saponins, which are natural detergents, actually bind cholesterol-containing bile acids and cholesterol itself, preventing it from being absorbed in the intestines," says nutrition researcher Peter Cheeke, PhD, professor emeritus at Oregon State University in Corvallis.
Yucca is creating excitement in scientific circles these days because early animal research suggests it may have broader effects than alfalfa in lowering cholesterol and preventing heart disease.
That’s because the plant’s stalk contains not only saponins, but resveratrol, a potent antioxidant that curbs disease-causing free radicals and reduces risk of heart disease in much the same way red wine does.
• The antioxidant cocktail. Another prospective answer to high cholesterol may lie in stronger blood vessels, say researchers in California. They recommend a complex vitamin regimen that contains vitamins C and E and Coenzyme Q10, plus a host of other heart healthy vitamins, minerals, and enzymes.4
"Our research shows that these substances help make blood vessels stronger and more flexible, helping force the fatty cholesterol deposits through them faster, and increasing the amount that can be eliminated," says nutrition researcher Aleksandra Niedzwiecki, PhD, research director of Matthias Rath Inc. in Santa Clara, CA.
Her research shows people who took her recommended combination decreased their total cholesterol by an amazing 14% in just 12 weeks, as well as an 8% increase in HDL. She recommends 500 mg of vitamin C, 400 IU of vitamin E, and 35 mg of Coenzyme Q10 daily.