“I feel better than I have in 30 years, but my cholesterol numbers are going up,” Kim said. “I don’t want to control my cholesterol with drugs. Every drug has side effects. I need to find a natural way to deal with this.”
Kim is not alone. Many people don’t want to take cholesterol-lowering drugs, and some people can’t take them. Statins are effective and considered safe for most people, but they raise the risk of side effects, including muscle aches, liver problems, mental fuzziness and the potential for developing diabetes.
“Nobody wants to start taking medicine,” said Donald Hensrud, associate professor of nutrition and preventive medicine at the Mayo Clinic College of Medicine. “We all age, and things usually go up with age: cholesterol, weight, blood pressure. At some point, people are faced with this.”
Cholesterol is a waxy, fatlike substance in the blood produced by the liver and from the food we eat. There are two kinds: low-density lipoprotein or LDL, the “bad” cholesterol, and high-density lipoprotein, or HDL, the “good” kind. (Think ‘L’ for lethal and ‘H’ for healthy.) Triglycerides — another type of fat — also contribute to cholesterol buildup. Cholesterol is measured in milligrams per deciliter of blood — or mg/dl. Ideally, healthy people should have an LDL of 100 mg/dl or lower and an HDL above 60.
Cholesterol is not inherently bad — the body uses it to make cells, vitamins and certain hormones — but too much LDL can build up inside the arteries, raising the danger of heart disease and stroke. A high HDL level, on the other hand, helps protect the heart by carrying some of the LDL away from the arteries and back to the liver, where it is broken down and eliminated.
For those who shun drugs, experts say the best way to control cholesterol is through a disciplined diet and such healthy habits as regular exercise and sufficient sleep. One caution: Be sure to check with your doctor before quitting medication. They can also order periodic blood tests to monitor your cholesterol.
“When people are willing to adhere to an optimal diet, there’s no question it’s better than any medicine we’ve got,” said David Katz, past president of the American College of Lifestyle Medicine and founding director of Yale University’s Yale-Griffin Prevention Research Center.
And there are other health benefits, such as losing weight and decreasing “blood pressure and blood glucose that will reduce the risk of heart disease separate from cholesterol,” Hensrud said.
Experts recommend a plant-based diet high in soluble fiber — oatmeal, oat bran, beans, apples, peas, citrus fruits, carrots, barley, flaxseed, a gel-forming powder called psyllium, as well as nuts and plant sterols, which are found in small amounts in fruits and vegetables, extra virgin olive oil, and nuts, and also added to some spreads, milks and yogurts.
They also urge consumers to avoid saturated fats, typically found in fatty and processed meats, butter, and in tropical oils such as palm and coconut. Go for unsaturated oils or polyunsaturated oils, such as corn, canola, sunflower and sesame. Saturated fat does more to raise blood cholesterol than naturally occurring cholesterol in eggs and shellfish, experts said.
Surprisingly, some research suggests that unprocessed cheese in moderation lowers the risk of cardiovascular disease. “It may be the one exception to the rule of lowering saturated fat, if not eaten to excess,” Hensrud said.
What about eggs? Americans have had a complicated relationship with eggs, “one year they are bad, and the next they are okay,” Hensrud said. “Egg whites are pure protein, it’s the yolks that have dietary cholesterol and a small amount of saturated fat. They increase risks, but not a huge amount, which is why the American Heart Association suggests up to one egg a day.”
A plant-based eating plan
Many experts recommend the Portfolio diet, a plant-based eating plan designed by David Jenkins, university professor in the departments of nutritional sciences and medicine, Temerty faculty of Medicine at the University of Toronto. It heavily emphasizes eating soluble fibers and sterols and eliminating processed foods. An early study conducted by Jenkins and his colleagues compared the cholesterol- lowering effects of the Portfolio diet with those of statins and found no significant differences.
“We need to have more emphasis on helping people understand these plant-based diets,” Jenkins said. “Some people have never tasted a lentil stew, for example. It can be delicious as well as nutritious and good for cholesterol levels. We are keen to enable people to learn how to eat a plant-based diet. I know it can be difficult, which is always a problem with any diet.”
People don’t have to transition abruptly, he said. “Begin by introducing a few foods gradually,” he said. “The idea is to move toward making plant-based eating a way of life.”
Katz agreed, saying it’s easy to retrain taste buds: “Taste buds are adaptable little fellas. When they can’t be with the foods they love, they love the foods they’re with.”
Be cautious with dietary supplements, which are largely unregulated by the Food and Drug Administration. For example, Hensrud advised against using niacin, which lowers cholesterol but has side effects, among them flushing. It also can raise liver enzymes when taken in large doses, Hensrud said. “Nobody should be using it anymore,” he said.
When statins can’t be avoided
Some people can’t lower their LDL without medication because of genetic conditions that predispose them to high cholesterol, chief among them familial hypercholesterolemia, or FH, a heritable defect in the body’s ability to process LDL. “They will always have to take statins,” combined with other drugs, Jenkins said, although those who are strict about diet and lifestyle still may benefit.
One of Jenkins’s patients with the disorder, for example, refused medication — against medical advice — and lowered her LDL through exercise and the Portfolio diet, although “not as low as we would like,” Jenkins said. Nevertheless, “it’s brilliant compared to what it was when she first came to see us,” Jenkins said. “She improved unexpectedly well due to extreme diet attention, which is very, very rare.”
Not everyone with a family history has FH. Kim is one of them. She plans to try diet and exercise. “I believe that I will be able to do this,” she said.
“All involve minimally processed foods and mostly plant products,” said Hensrud, author of the book “The Mayo Clinic Diet.” “The composite effect generally will be to lower LDL. This gives people choices. You can select what appeals to you from each of them.”
But the Portfolio diet is “the definitive dietary response to cholesterol,” Katz said.
“Keep in mind, though, that the only effective diet is the one you are willing to eat,” he added.
Do you have a question about healthy eating? Email [email protected] and we may answer your question in a future column.
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