Elevated Cholesterol 1: If I have high cholesterol levels, can a healthy way of eating help me lower them into a normal range?

Absolutely! In fact, a study published in the July 2003 issue of the Journal of the American Medical Association in which a whole foods diet was compared head-to-head with treatment by statin drugs found the whole foods approach to be so effective that the Comment accompanying this JAMA article is entitled, "Diet first, then medication for hypercholesterolemia (high cholesterol)."

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Foods for Healthy Cholesterol Levels
Nutrient	Foods	Benefits
Soluble fiber*	Whole grains, oat bran, barley , peas, beans (all types, especially soy), nuts	Lowers LDL and improves ratio of LDL to HDL
Niacin* (if LDL levels are already high, supplements may be necessary to reduce levels)	Salmon, tuna, chicken, calf liver, halibut, asparagus, crimini mushrooms	Helps decrease the body's production and increase its elimination of cholesterol, prevents oxidation of LDL and can increase levels of HDL cholesterol
Vitamin E*	Swiss chard, sunflower seeds, spinach, kale, mustard greens, almonds, walnuts	Helps prevent prevent the oxidation of LDL cholesterol
Vitamin C*	Citrus fruits, broccoli, red bell peppers, kale, Brussels sprouts, kiwifruit	Helps prevent the oxidation of cholesterol
Flavonoids, including naringenin	Citrus fruits, especially grapefruit	Lowers LDL and triglycerides
Beta carotene*	Carrots, sweet potatoes, winter squash, kale	Helps prevent the oxidation of LDL cholesterol
Polyphenols, including pterostilbene	Cranberries, grapes, blueberries, olive oil	Help prevent oxidation of cholesterol and increase levels of HDL cholesterol
Phytosterols	Sesame, pumpkin, sunflower seeds	Help lower cholesterol
Unsaponifiables	Brown rice	Lowers LDL cholesterol
Probiotic bacteria	Yogurt	Lowers LDL, increases HDL cholesterol
Foods rich in taurine and omega 3 fatty acids (e.g., cold water fish), monounsaturated fats (e.g., olive oil , avocado, walnuts, almonds ) and the allium family of vegetables (e.g., garlic, onions) can also be helpful. These foods' cholesterol-lowering benefits are discussed below under "How Foods Help Lower Cholesterol". Whole soyfoods, but not isolated soy protein or isoflavones, have also been shown to significantly lower LDL while raising HDL cholesterol.These studies are discussed below under "Research Studies Confirm the Importance of Eating Whole Foods on Healthy Cholesterol Levels." Mediterranean Diet. Following a Mediterranean diet has been linked to lower levels of oxidized LDL and lower incidence of cardiovascular disease. This research is discussed below under "Research Studies Confirm the Importance of Eating Whole Foods on Healthy Cholesterol Levels."
*Click on link for a complete list of foods rich in these nutrients.

(For more discussion of recent studies see below: Research Studies Confirm the Importance of Healthy Foods and Healthy Cholesterol Levels.)

What foods may help me lower my LDL cholesterol and maintain or improve my ratio of LDL to HDL to healthier levels, e.g., 175 mg/dL with a 4:1 ratio of LDL:HDL ?

It's not just about counting cholesterol and calories from saturated fat in your diet that determines your cholesterol levels, but which foods you choose to eat, shows a study published in the May 2005 issue of the Annals of Internal Medicine.

The effects of two low-fat diets identical in total fat, saturated fat, protein, carbohydrate and cholesterol content-but differing in the amount of fruit and vegetables included-were compared in a group of 120 adults aged 30 to 65 with moderately high cholesterol levels. Both diets met American Heart Association Step I guidelines to obtain 30% of energy or less from total fat and 10% of energy or less from saturated fat.

One diet was typical of a low-fat U.S. diet, while the other incorporated considerably more vegetables, legumes, and whole grains.

After just four weeks, while those on typical low-fat diet dropped their total cholesterol 9.2 mg/dL and LDL cholesterol 0.18 mmol/L, study participants eating the low-fat diet rich in nutrient-dense plant-based foods saw their total cholesterol plummet 17.6 mg/dL and LDL 0.36 mmol/L.

The plant-rich diet dropped LDL more than twice as much as the conventional low-fat diet. Christopher Gardner, assistant professor of medicine at Stanford University, California, and lead author for the study, noted that doctors have just looked at what not to eat, and now need to emphasize health-promoting foods. "We were so focused on the negative-just what to avoid-and not what to include," he said.

In addition to a diet rich in fruits and vegetables and low in saturated fats, soluble fiber from foods such as oats, peas and beans (especially soy beans), has been found to lower elevated levels of LDL and improve the ratio of LDL to HDL.

Cold water fish, garlic and onions, olive oil and other sources of monounsaturated fats have also been shown to lower LDL, while cranberries, soy foods and niacin have been found to raise HDL.

Supplemental niacin has also been found to not only help reduce LDL levels, but to raise levels of protective HDL; however, it is important that you check with your health care practitioner before taking supplemental niacin for this purpose. Niacin is available in a number of different forms, one of which may be significantly more helpful for you than another. In addition, some forms of niacin may cause unpleasant flushing in some individuals. Your health care practitioner can help you maximize the benefits and minimize the potential side effects of supplemental niacin. If you want to lower your cholesterol levels or even if you've never had any problems with high cholesterol and just want to maintain healthy levels, enjoying the Healthiest Way of Eating with the World's Healthiest Foods can help keep your cholesterol levels in check.

In fact, a review of human clinical studies conducted by Annie Lapointe and colleagues from Laval University in Quebec, and published in the February 2006 issue of the Journal of Nutritional Biochemistry has confirmed that following a Mediterranean-style diet, rich in olive oil, fruit and vegetables and fish-the diet recommended by the World's Healthiest Foods-is better than taking supplements to protect against cardiovascular disease.

Lapointe believes a Mediterranean-style diet is more effective against cardiovascular disease because a highly protective synergy occurs among the wide variety of dietary antioxidant vitamins, healthy monounsaturated fats, and flavonoid-rich foods this healthy food pattern supplies.

The synergistic effects produced by the combination of many antioxidant compounds and flavonoid-rich foods in a Mediterranean-style diet significantly reduce the susceptibility of LDL cholesterol to oxidation (free radical damage). Since only after LDL has been oxidized does it become involved in the development of atherosclerosis, this may help explain the cardiovascular benefits of the Mediterranean diet. In March 2005 in the Journal of Nutrition, Lapointe's team published research conducted in Quebec in which 71 healthy women were provided with nutrition information and helped to follow a Mediterranean diet for 12 weeks. By the end of the study, the women's blood levels of oxidized LDL had dropped by 11.3%.

Cholesterol is Not Inherently Bad for the Body:

In fact, without cholesterol, your body would be unable to make hormones, cell membranes or vitamin D. Normally, cholesterol flows through the blood vessels without causing any damage or the build-up of atherosclerotic plaques. It¡¯s only if cholesterol becomes oxidized by free radicals in the body that it can become problematic. That is why eating foods rich in antioxidants is so important. Foods rich in antioxidants, such as vitamins E, C and beta carotene, can help prevent the oxidation of cholesterol and the damage it may cause to blood vessels.

Eating a Variety of Cholesterol-Lowering Foods Has Additive Beneficial Effect

A study published in the October 2004 issue of the British Journal of Nutrition underscores the additive beneficial effects that result when foods independently known to lower cholesterol are combined in a healthy way of eating. In this study of 12 patients with elevated LDL cholesterol levels, a diet containing soy protein, almonds and other nuts, plant sterols (also found in nuts), and soluble fiber (in high amounts in beans, oats, pears) reduced blood levels of all LDL fractions including small dense LDL (the type that most increases risk for cardiovascular disease) with near maximal reductions seen after only 2 weeks.

Combination of Cholesterol-Lowering Foods Drops LDL by More than 20%

A diet that includes a combination of cholesterol-lowering foods, such as soy, plant sterols, almonds and viscous fibers, can reduce LDL-cholesterol levels by 20% or even more, shows a follow up to the October 2004 study, which was published in the March 2006 issue of the American Journal of Clinical Nutrition.

This year-long study followed 55 volunteers with high cholesterol levels. Subjects ate a diet that, for every 1,000 calories, included one gram of plant sterols, 10 grams of viscous fiber, 22.5 grams of soy protein, and 23 grams of whole almonds.

Enriched margarines were used as the source of plant sterols (for whole food sources of plant sterols, see below), the fiber came from oats, barley, okra and eggplant, and the soy proteins came from soy milk and tofu. Participants were also instructed to eat five to ten daily servings of fruit and vegetables.

Regular blood tests during the year allowed the researchers to measure total cholesterol, triglycerides and HDL cholesterol levels. LDL levels were calculated from these results.

Average cholesterol reductions at 3 months and 1 year were 14% and 12.8, respectively-less than those observed after treatment with statins; however, 31.8% of study participants had reductions of LDL-cholesterol of more than 20% at 1 year, which is similar to results from statin therapy and equivalent to a 30% reduction in risk of death from heart disease.

HDL-cholesterol levels were also increased, and a small but significant 13% reduction in blood levels of triglycerides was noted. The researchers also reported a "small but statistically significant" loss of weight among the participants.

Those who best followed the dietary recommendations experienced the largest drops in LDL-cholesterol levels. Participants found it easiest to incorporate the almonds and plant-sterol margarine into their daily lives with 79% and 67% of volunteers, respectively, reaching the targets for their intake. Fiber and soy protein were more challenging since neither are found in most fast foods, so they require a little grocery list planning; their targets were reached a bit less, by 55% and 51%, respectively.

More than 30% of motivated participants who ate the dietary portfolio of cholesterol-lowering foods under real-world conditions were able to lower their LDL-cholesterol concentrations more than 20%, which was not significantly different from their response to a first-generation statin.

"The study's findings suggest that the average person can do a lot to improve their health through diet," said Jenkins.

Plant sterols are naturally occurring components of plant cell membranes just as cholesterol is a part of animal cell membranes. The three most abundant sterols are: ?-sitosterol, campesterol, and stigmasterol.

A word of caution about plant sterol-enriched margarines

Plant sterol-enriched margarines (such as Benecol or Take Control), can contain trans fats despite their claim to be trans fat-free. This misleading claim can legally be made because under the 2006 regulations that demand disclosure of trans fats, the FDA allows manufacturers to round to zero any ingredients that account for less than 0.5 grams per serving. (In the case of margarines, a limit of one half gram per tablespoon is applied). The new legislation also permits manufacturers to say "zero trans fats" on the label if the above standard has been met. If a person used 4 tablespoons of a sterol-enriched, "trans free" margarine over the course of a day (not only as a spread on toast or baked goods but in a recipe, for example), that person would be getting about 2 full grams of trans fat from this "trans free" product. To put that amount in perspective, a July 2002 report from the Institute of Medicine at the National Academy of Science declared that the upper limit for trans-fats in the diet should be zero. The consumption of 2-3 grams a day of trans fats increases the risk of coronary heart disease by 21%. It's important to be equally cautious about an enriched margarine that is truly trans free. Some enriched margarines in the marketplace advertise themselves as "trans free" and actually are trans free. (Smart Balance is one example). However, these enriched margarines usually become trans free by increasing their saturated fat percentage-not a recommended strategy from our perspective.

For those who would prefer to get their plant sterols from whole foods, these compounds are present naturally, although in smaller amounts than in sterol-enriched margarines, in all plant foods. The highest concentrations of plant sterols are found in unrefined vegetable oils, nuts, seeds, legumes, and whole grains.

In 2000, the FDA authorized a health claim describing the relationship between dietary intake of plant sterols and reduced risk of heart disease. That health claim states that "Foods containing at least 0.65 grams per serving of plant sterol esters, eaten twice a day with meals for a daily total intake of at least 1.3 grams, as part of a diet low in saturated fat and cholesterol, may reduce the risk of heart disease."

As the table below shows, a healthy way of eating featuring daily selections from the whole foods listed below can easily deliver 1.3 grams of cardio-protective plant sterols.

Phytosterol Content of Selected Foods
Food	Serving	Phytosterols (mg)
Wheat germs	1 ounce	114-118
Sesame seed	1 ounce	133-138
Pumpkin seeds	1 ounce	88
Pistachio	1 ounce	90-96
Sunflower seeds	1 ounce	77-82.5
Unrefined Canola oil	1 TBS	91
Peanuts	1 ounce	62
Wheat bran	1/2 cup	58
Almonds	1 ounce	34
Brussels sprouts	1 ounce mg	34
Rye bread	2 slices	33
Macadamia nuts	1 ounce	33
Extra virgin olive oil	1 TBS	22

For more information on cholesterol see:

• Elevated Cholesterol 2 - What is high cholesterol and what levels of LDL and HDL are considered healthy?
• Elevated Cholesterol 3 - What foods and nutrients are good for healthy cholesterol levels?
• Elevated Cholesterol 4 - What foods should I consume sparingly or avoid to promote healthy cholesterol levels?
• Elevated Cholesterol 5 - Recent research studies confirm the importance of eating healthy foods on healthy cholesterol levels

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