Cardiovascular disease is the number one cause of mortality globally. Heart disease is responsible for a third of all deaths in the world. In this article we discuss how to reduce the cardiovascular risk by reducing cholesterol levels.
What type of nutritional guidelines should one follow to lower cholesterol?
Generally, a plant-rich diet is recommended. Saturated fat (no more than 5-6% of calories) should be avoided according to the America Heart Association (AHA).
We want to limit/eliminate added sugar, alcohol, processed and fried foods, and we want to limit animal fats (such as cheese and red meat, especially). Healthy fats from plants, nuts, olive oil, avocado oil should all continue to be part of the nutritional plan in moderation and balanced with whole foods with high fiber. Eggs are generally acceptable in moderation (for some, 1 egg/day may be acceptable), as cholesterol in diet does not increase blood cholesterol levels in most people (although we generally recommend elimination or reduction of egg yolks and reassessing, as they may be contributing to overall risk). Fiber coming predominantly from non-starchy vegetables, but also from low glycemic load fruit, as well as legumes, is also important.
When I counsel people about nutritional modifications to support healthy cholesterol levels, I typically recommend that they work with a registered dietitian or nutritionist to create and implement a sustainable plan that will lower their cardiovascular disease risk. Our registered dietitian and the patient partner to come up with a plan together that is both doable and reduces their risk.
What causes high triglycerides?
Sedentary lifestyle or lack of adequate exercise, consumption of foods high in sugar, simple carbohydrates and fat, and excess alcohol consumption can all contribute to high triglycerides. Certain health conditions, such as, diabetes, hypothyroidism, liver disease and overweight and obesity can also cause high triglycerides.
What are the downstream effects of high cholesterol?
High cholesterol is a risk factor for cardiovascular complications including heart attack and stroke. These complications arise from cholesterol build up in arterial walls and resulting inflammation, narrowing and eventual blockage of the artery. When the artery is blocked, and blood flow is obstructed, this can cause a heart attack or stroke (depending on the location of the blocked artery).
What do people mean when they say “good cholesterol” or “bad cholesterol”?
Cholesterol is essential for life. The terms “good” and “bad” cholesterol refers to HDL being “good” and LDL cholesterol being “bad” – these are misnomers. LDL cholesterol measures the amount of cholesterol associated with LDL particles – the particles that can cause atherosclerosis. HDL cholesterol measures the cholesterol associated with HDL particles that help remove cholesterol from artery walls.
When LDL (low density lipoprotein) is elevated, it accumulates in the wall of blood vessels (e.g., inside the artery of the heart) to form plaque, and inflammation ensues. This causes the lumen (the inside) of the artery to narrow, or eventually become obstructed, which compromises blood flow. This leads to complications such as heart attack or stroke.
In other words, high level of LDL cholesterol is a risk factor for cardiovascular disease. Low level of HDL is a risk factor for cardiovascular disease. There is much more nuance with respect to HDL, in particular. High levels of HDL are not necessarily as protective as previously thought. Dr. Daniel Radner found that “protective effects of HDL are more dependent upon how it functions than merely how much of it is present”.
What is the evidence-based treatment of high cholesterol?
The treatment modalities used and treatment targets for lipid levels largely depend on the individual’s cumulative risk factors.
The foundation of treatment starts with lifestyle and nutrition. Medications are added, when appropriate, based on risk, lipid levels, lipid targets and other co-morbid conditions.
Are there any additional benefits of supplements and/or herbal remedies?
Avoidance of foods associated with elevated cholesterol levels, as noted above, is recommended.
Incorporating a high fiber, plant-based diet, “Mediterranean-style” diet is recommended.
Additionally, the American Heart Association recommends limiting saturated fats to no more than 5-6% of calories in diet.
REDUCE-IT trial found that in people with high triglyceride levels who were on statin medications, the risk of cardiovascular events was lowered in individuals who took 2g of icosapent ethyl twice daily (a modified version of EPA, an omega 3 fatty acid), compared to those taking placebo.
Patients often ask me about red yeast rice (RYR). Lovastatin is the active component of RYR, however there is a variation in dosing and benefits on LDL reduction may not be adequate. There is research suggesting a reduction in cardiovascular risk with RYR. Risks are similar to those associated to statin use.
RYR contains monacolin K, which is lovastatin, and eight other monacolins, along with sterols, isoflavones, and monounsaturated fatty acids. This family of substances may explain why RYR is more effective at reducing cholesterol than would be expected with the small amount of lovastatin that it contains (note that there is great variability in monocolin levels among products). Based on a meta-analysis of randomized controlled trials of RYR, HDL-C can be raised by 15-22%, LDL-C can be lowered by 27-32%, and TG by 27-38%.
From the National Center for Complementary and Alternative Medicine (NCCAM, 2014).
• The U.S. Food and Drug Administration (FDA) has determined that red yeast rice products that contain more than trace amounts of monacolin K are unapproved new drugs and cannot be sold legally as dietary supplements.
• Some red yeast rice products contain a contaminant called citrinin, which can cause kidney failure.
While there are other supplements that have been found to lower cholesterol levels, the reduction is often modest with supplements alone. Bergamot and berberine are often used and can result in a reduction in LDL. Psyllium husk can be used as an adjunct to cholesterol lowering therapy, or alone if medications are not warranted. It is important to note that we don’t have cardiovascular outcome data with supplemental use. As a result, if someone has clear indications for cholesterol-lowering therapy, supplements are not a substitute for this.
What cholesterol lowering medications are used as first line?
There are a number of medications available for cholesterol lowering. The decision to start cholesterol lowering therapy should be discussed with a qualified physician or healthcare clinician and align with research and guidelines available. It should also be personalized to each individual once their specific risk factors are understood and quantified.
Statin therapy is the mainstay of pharmacological cholesterol lowering treatment and cardiovascular risk reduction. In patients with high risk or not achieving target lipid levels with a statin alone, other medications may be added to statin therapy (e.g., ezetimibe), and for individuals intolerant to statins, other medications are available (e.g., PCSK9 inhibitors).
To learn more about comprehensive lipid profile markers that indicate risk of cardiovascular disease, you may read this article. Additionally, in the appropriate patient populations, studies such as coronary artery calcium (CAC) score and cardiac computed tomography angiography (CCTA) can be useful tools in assessing the extent of coronary artery disease and can support pharmacotherapy decisions.