Think of atherosclerosis as sludge in the arteries. Because it can lead to heart attacks and strokes, this condition is the leading cause of death in Americans older than 45. For most people, atherosclerosis begins slowly and sneakily in childhood and progresses year by year. The process seems to begin with an injury to an artery’s lining. Factors that can harm this delicate lining include high blood pressure, tobacco byproducts and an amino acid called homocysteine, which is generated by the breakdown of protein.
Cholesterol and other fats become trapped at the damaged site. When these fats accumulate, they become oxidized. (Oxidation is the same process that has butter go rancid and iron turn to rust.) These rancid blood fats are taken up by smooth muscle cells just beneath an artery’s inner lining. An assortment of cells migrate toward the site, hang about and generally cause trouble. This microscopic mob scene represents a plaque.
The problem with arterial plaques is that they impede blood flow. They also can break free and lodge in sometimes fatally inconvenient places, such as the arteries that would otherwise deliver blood to your brain or heart. When this happens, you end up with a stroke or a heart attack.
The Good and the Bad
Cholesterol itself is not evil. Our livers manufacture cholesterol — whether or not we eat any — because our bodies need it to maintain healthy cells and to make hormones. Most of us, aside from strict vegetarians, eat a good deal of the stuff by way of meat, poultry, fish, eggs and dairy products.
Cholesterol is shuttled within the body by lipoproteins (carriers made of fat plus protein). LDL cholesterol (also known as “bad” cholesterol) transports cholesterol to the tissues. This is the type of cholesterol you want to lower. HDL cholesterol (“good” cholesterol) transports cholesterol to the liver, where it is metabolized and excreted into the intestinal tract.
About 102 million American adults have total cholesterol levels that are borderline high (200 to 239 mg/dL), and 41 million have levels that are definitely high (more than 240 mg/dL). Some people are genetically unlucky — their bodies simply make too much cholesterol. For the majority of us, though, high cholesterol stems from lifestyle factors.
A wealth of research shows that lowering blood cholesterol reduces the risk of heart attack. The solution lies in cleaning up Homer Simpson-type habits. Pioneering research by Dean Ornish, M.D., author of Dean Ornish’s Program for Reversing Heart Disease (Ivy, 1996), demonstrates that comprehensive lifestyle changes not only can prevent heart disease but actually reverse atherosclerosis. Such changes include good eating habits, exercise and stress reduction. People with borderline high cholesterol may want to add herbs and vitamins to that regimen. People who have documented high cholesterol may want to take a prescription medication to get things under control.
Eat wisely. “In parts of the world where people eat diets based on starches, vegetables and fruits, atherosclerosis is extremely rare,” says John McDougall, M.D., author of The McDougall Program for a Healthy Heart (Plume, 1998). “In the United States, where we eat too few of these plant foods, heart attacks are our number-one killer.” McDougall is also the founder of the McDougall Program at St. Helena Hospital in California’s Napa Valley.
According to studies published in the Archives of Internal Medicine and the American Journal of Clinical Nutrition, people who eat a diet of fruits, vegetables, beans, fish, poultry and whole grains have significantly lower risk of having a heart attack compared to those who eat a Western diet rich in sweets, fried foods, high-fat dairy products, refined grains, and red and processed meats.
If you lower your consumption of animal products, you’ll automatically reduce your intake of cholesterol, saturated fats and methionine — an amino acid the body converts to homocysteine, which raises the risk of heart disease.
By putting fruits, vegetables and whole grains at the base of your food pyramid, you’ll take in antioxidants, which prevent LDL cholesterol from oxidizing, and fiber, which binds cholesterol in the intestines to enhance its elimination. Water-soluble fiber is best at lowering cholesterol. Sources include psyllium seeds (Plantago spp.), oats, apples and beans.
A 2003 study published in the Journal of the American Medical Association found that a diet high in plant sterols, soy protein and almonds lowers cholesterol as much as lovastatin, a prescription cholesterol-lowering drug. The study participants also included eggplant, okra, barley and psyllium in their diets.
Fat facts. It’s important to understand which fats are bad for your arteries. The general rule of thumb is that “bad” fats are solid at room temperature. Saturated fat, trans fatty acids and dietary cholesterol raise blood cholesterol. Saturated fats and dietary cholesterol come from animal products. Trans fats arise when polyunsaturated fats (vegetable oils) are exposed to high heat (e.g., when cooking french fries) and when liquid vegetable oils are solidified in a process called hydrogenation. Trans fats are commonly found in margarine, crackers and processed snack foods.
Monounsaturated fats and polyunsaturated fats don’t raise cholesterol. Canola oil, olive oil, peanut oil and avocados contain monounsaturated fats. Safflower, sesame and sunflower seeds, corn, soybeans and many nuts contain polyunsaturated fats. Some studies suggest these oils might even help lower LDL cholesterol slightly when eaten as part of a low-saturated-fat diet.
More about fiber. Oats have been the subject of a number of studies. Turns out, they lower cholesterol, triglycerides and blood pressure. Oat bran is a soluble fiber, which increases the elimination of cholesterol in bile. In other words, cholesterol gets trapped in the intestines and is eliminated in the stool. Fans of amaranth cereal should know this grain also lowers cholesterol. Wheat, however, does not.
Beans figure in the list of soluble-fiber-rich foods. Remember the schoolyard chant, “Beans, beans, good for your heart . . .”? Well, it’s true. According to a 2001 study from the Archives of Internal Medicine, people who eat beans four times per week reduce their heart-disease risk by 20 percent. Any legumes will do — try lentils, pinto beans, black beans or soybeans. If you’re moving toward a near-vegetarian diet, beans provide a stick-to-your-ribs substitution for meat.
Move your body. Exercise lowers cardiovascular risk factors by keeping weight in check, strengthening the heart, relieving stress, improving circulation, raising HDL cholesterol and lowering blood pressure and triglyceride levels. Brisk walking is McDougall’s exercise of choice, especially for people who already have heart disease. Walk for 20 to 30 minutes four or more times weekly. According to a 2001 study published in the Journal of the American Medical Association, women who walk regularly (even at a leisurely pace) have a 50 percent lower chance of having a heart attack or needing surgery for blocked coronary arteries.
Be lean. Excess weight contributes to high blood pressure, elevated cholesterol levels and diabetes — each a risk factor for heart disease. Research shows that obesity can quadruple your odds of dying from heart disease and that losing weight can lower risk factors. Your main allies in the battle of the bulge are a healthy diet and exercise.
Stop smoking. Among other evils, cigarette smoke injures the arterial lining, constricts coronary arteries, elevates and oxidizes LDL cholesterol, lowers HDL cholesterol, raises triglycerides and promotes clot formation. Fortunately, heart attack risk tapers off soon after kicking the habit.
Enjoy the red grape. Moderate drinking lowers heart disease risk, but heavy drinking (more than two drinks per day) increases the risk. Moderate drinking is about one drink per day for women; two for men. Although any kind of alcohol has cardiovascular benefits, red wine has the additional benefit of being rich in bioflavonoids that decrease platelet stickiness (to discourage abnormal blood clots) and act as strong antioxidants. Antioxidants help mop up damage caused by free radicals, marauding chemicals that can injure tissues (including arterial linings) and alter LDL cholesterol so that it’s more likely to cause atherosclerosis.
Blue, purple and red berries, as well as purple grapes and their juices, contain these bioflavonoids. Research shows that 8 or 10 ounces per day of red grape juice protects the vessels, without the risks associated with alcohol. Likewise, grapeseed extract, which concentrates these potent bioflavonoid antioxidants, has been shown to lower cholesterol deposits in the arteries of animals.
Take time to relax. Intuition and scientific research support the notion that hostility and anxiety stress the cardiovascular system and that a mellow state of mind can mend it. One study, published in a 1999 issue of the Journal of Psychosomatic Research, looked at the impact of “daily hassles.” As hassles rose, the cholesterol to HDL cholesterol ratio increased. According to a study published in the journal Stroke, a particular type of meditation, Transcendental Meditation, has been shown to reduce stress, blood pressure, cholesterol and atherosclerosis.
All these basic lifestyle changes are critical to heart health. And they work. Data from the Harvard School of Public Health’s Nurses’ Health Study confirms that women who don’t smoke, keep their weight down, exercise at least 30 minutes daily and eat healthy food reduce their chances of developing heart disease by a whopping 82 percent.
Second measures. McDougall says when his patients can’t control cholesterol with lifestyle changes, he recommends natural remedies, such as garlic, oat bran and niacin. He reserves prescription medications for those people who continue to have high cholesterol levels and other heart disease risks.
Helpful Vitamins — Bs and Antioxidants
Niacin, also called vitamin B3, raises HDL cholesterol and lowers LDL cholesterol and triglycerides. Even though it raises homocysteine levels, it nonetheless reduces the risk of death due to heart disease. McDougall calls niacin “the most potent drug available to raise HDL cholesterol.”
In a 1994 study published in the Archives of Internal Medicine, niacin was compared to the cholesterol-lowering medication lovastatin (Mevacor). The drug produced a greater reduction in LDL cholesterol (32 percent versus 23 percent for niacin), but niacin increased HDL cholesterol much more than lovastatin (by 33 percent versus 7 percent for lovastatin). For this reason, niacin is often combined with statin medications.
Indeed, a 2002 study by The American Journal of Cardiology found that combining a statin medication with niacin was a safe and effective way of managing high cholesterol in people who didn’t respond completely to the statin alone. This combination can cause atherosclerotic narrowing of arteries to actually regress.
Niacin does have its drawbacks. The most noticeable problem is skin flushing that begins 20 to 30 minutes after swallowing the pill, then abates. Less commonly, people can develop gastric irritation, nausea and liver damage. Immediate-release niacin is most likely to cause flushing. Sustained-release niacin reduces flushing but raises the risk of liver toxicity. Extended-release delivers niacin to the system at an intermediate level, reduces flushing and is not as likely to cause liver damage.
For this reason, McDougall recommends either immediate-release niacin (available over the counter) or an extended-release formulation called Niaspan (available by prescription at a greater cost). The dosage is 500 mg taken in the evening with a little food and increased every one to four weeks by 500 mg to a maximum of 2,500 mg. Usually 1,000 to 1,500 mg does the trick.
Another form of niacin, called “flush-free” or “no-flush,” also is available. Anecdotal evidence suggests this form, which causes no flushing, is effective for many people. However, specific research on this form has not been conducted.
McDougall stresses that people take high-dose niacin only under a doctor’s supervision with regular monitoring of liver function. People who already have liver disease should not take it. Because niacin can impair glucose tolerance, people with diabetes should not take high doses without a physician’s supervision.
Other B vitamins play a role in lowering blood levels of homocysteine, which is another risk factor for cardiovascular disease. Maintaining adequate dietary intake of folic acid, vitamin B6 and vitamin B12 can help keep homocysteine levels in check. In people with atherosclerosis, supplements of folic acid (2.5 mg), vitamin B6 (25 mg) and vitamin B12 (250 mcg) induced regression of atherosclerosis, according to a 2000 study from the American Journal of Hypertension. A 2001 Archives of Internal Medicine study found the optimal dosage of folic acid is 800 mcg per day.
Because oxidation of cholesterol and the arterial lining play a role in atherosclerosis, scientists figured that antioxidant vitamins might help. Indeed, a number of population studies have suggested people who eat diets rich in antioxidant vitamins have a reduced risk of coronary artery disease. However, several clinical trials of vitamin E, beta-carotene and other natural antioxidants have failed to show a beneficial effect once people already have serious heart disease. Also, antioxidant supplements have been shown to interfere with a key beneficial effect of the cholesterol-lowering drugs niacin and simvastatin (Zocor) — raising HDL.
Until the issue of antioxidant supplements is further worked out, it never hurts to eat plenty of fruits and vegetables (for vitamin C and carotenes) and nuts (for vitamin E).
Garlic (Allium sativum). Michael Castleman, author of Blended Medicine (Rodale, 2000), The New Healing Herbs (Rodale, 2001) and many other health books calls garlic “the ultimate herb for preventing heart attack and stroke.” It has antioxidant activity and can protect LDL cholesterol from oxidation. It mildly lowers blood pressure, inhibits platelets from clumping (a step in blood clot formation), enhances the breakdown of clots within blood vessels, makes LDL cholesterol more resistant to oxidation and diminishes the arterial stiffness that comes with age and high blood pressure. Garlic lowers triglycerides and LDL cholesterol and raises HDL cholesterol; the plant’s sulfur-containing compounds inhibit the liver’s manufacture of cholesterol.
Although two 1998 studies failed to find benefit from garlic supplements, at least 14 other studies have demonstrated that garlic preparations decrease total serum cholesterol and LDL cholesterol. Overall, the herb lowers cholesterol by about 12 percent. “The total weight of the evidence shows that garlic lowers cholesterol, particularly when used as part of a comprehensive program,” Castleman says.
In a 2001 study published in the Journal of the American College of Nutrition, researchers compared enteric-coated garlic powder tablets (containing 9.6 mg allicin-releasing potential) with a placebo in treating people with high cholesterol who had not improved on drug therapy. After 12 weeks, the garlic group had significant reductions in total cholesterol and LDL cholesterol, while the placebo group had a slight increase in both of these blood fats. A four-year study of people with advanced atherosclerosis, published in the journal Atherosclerosis, found that 900 mg per day of a standardized garlic powder shrank atherosclerotic plaques 2.6 percent, compared to a 15.6 percent increase in the placebo group.
When garlic is chopped, the enzyme allinase converts the sulfur-containing amino acid alliin to allicin, which produces garlic’s renowned odor and most of its therapeutic effects. Subsequent testing of garlic brands found that the lot used in one of the negative studies mentioned above had almost no detectable amount of allicin. Conversely, testing of the batch used in a positive study showed the products were higher in allicin. By the way, heat destroys allinase. Castleman notes that one of the studies showing garlic to be ineffective used steam-distilled garlic, which contains no allicin.
Most studies have used a dosage of 600 to 900 mg of powdered garlic that contained about 1.3 percent allicin. Many experts prefer raw garlic. How much is enough? Castleman says the research varies, from one or two cloves daily to up to 10 cloves. It depends how much your palate and digestion (and your friends) can handle.
Guggul comes from the resin of the mukul myrrh tree (Commiphora mukul), which is native to India. It has been used in Ayurvedic medicine for more than 2,000 years to treat a variety of ailments, including
cardiovascular disease. The active ingredient, guggulsterone, seems to lower cholesterol by increasing the rate at which the liver both takes up and breaks down LDL cholesterol from the blood.
The research on guggul isn’t as extensive as it is for garlic, yet a few studies have found that guggul, either alone or combined with garlic and onion, can lower cholesterol and triglycerides. In one study, published in Phytotherapy Research, cholesterol fell approximately 12.5 percent with guggul and 13.4 percent with allicin after eight weeks. In another, from Cardiovascular Drugs and Therapy, 61 people with high cholesterol adopted a fruit and vegetable-enriched diet. Half took a placebo; half took guggul for 24 weeks. Guggul decreased the total cholesterol level by 11.7 percent, the LDL cholesterol by 12.5 percent and triglycerides by 12 percent. None of these blood measurements changed in the placebo group. The authors wrote, “The combined effect of diet and guggul at 36 weeks was as great as the reported lipid-lowering effect of modern drugs.”
However, a 2003 study published in the Journal of the American Medical Association found no benefit when using guggul to lower cholesterol. Consult your health-care provider to find out if guggul is a good option for you.
If you choose guggul, use an extract standardized to contain 25 mg of guggulsterone in a 500-mg capsule; take one capsule three times daily. It may require four weeks for benefits to become apparent.
Soy (Glycine max). Eating soy products, particularly when substituted for meat, reduces cholesterol. In menopause, benefits arise from the isoflavones genistein and daidzein. With respect to the heart, it may be that the fiber, isoflavones and antioxidants in soy work together. According to a 2000 study published in the Journal of the American College of Cardiology, soy enhances liver metabolism of LDL cholesterol and also may lower blood pressure, reduce atherosclerosis and increase arterial elasticity.
Most studies show soy lowers both total and LDL cholesterol while raising HDL cholesterol. A 1995 analysis of 38 studies found that people who ate an average of 47 grams of soy protein per day reduced total cholesterol by 9 percent, LDL cholesterol by 13 percent and triglycerides by 10.5 percent. Several studies show that substituting soy protein for animal protein lowers cholesterol. However, a 2002 study of postmenopausal women with high cholesterol failed to find that soy (150 mg per day of soy isoflavones) significantly lowered cholesterol.
Because the weight of the evidence has been positive, the U.S. Food and Drug Administration has approved as acceptable health claims that soy, taken in the amount of 25 to 50 grams per day and combined with a diet low in saturated fat and cholesterol, has been shown to lower cholesterol levels.
A simple strategy is to incorporate soybeans (and other beans) into your diet. Snack on edamame and use textured vegetable protein, tofu and tempeh in lieu of meat.
Hawthorn (Crataegus spp.). This small, flowering tree enjoys a long European tradition as a heart tonic. Hawthorn is rich in bioflavonoids that help stabilize collagen, protect against free-radical damage and inhibit the inflammatory process. Extracts dilate the coronary vessels, thus improving blood supply to the heart; increase the heart’s ability to contract; mildly reduce blood pressure; reduce some rhythm disturbances; and reduce blood cholesterol. Lab studies suggest hawthorn extracts can reduce the size of atherosclerotic plaques.
Natural practitioners use hawthorn to prevent and reverse atherosclerosis, though the herb’s main claim to fame is in the treatment of mild to moderate congestive heart failure, a use supported by research.
The dose depends upon the type of preparation. Standardized flower extracts are usually taken in a dose of 100 to 250 mg three times daily. Tinctures are taken as 5 ml three times per day.
This gentle, slow-acting herb usually requires four to eight weeks for full benefit. Because hawthorn can augment the action of the heart drug digitalis, people shouldn’t combine the two unless under medical supervision.
The Downside of Prescription Cholesterol Drugs
Pharmaceutical cholesterol-lowering drugs, such as Lipitor (atorvastatin) and Zocor (simvastatin), work by blocking an enzyme needed by the body to make cholesterol. Depending on which statin is used, the reduction in LDL cholesterol ranges between 24 and 50 percent. HDL cholesterol generally rises 6 to 12 percent. Triglycerides fall 10 to 24 percent.
If you have a serious cholesterol problem, consult your health-care professional, as prescription drugs may be needed. However, these drugs can have several side effects, including nausea, constipation, diarrhea, intestinal gas, stomach pain, heartburn, headache, skin rash and dizziness. Less common are hepatitis (liver inflammation, which occurs in less than 1 percent of patients given high doses), muscle pain, severe stomach pain, fatigue, weakness, decreased sexual ability and trouble sleeping.
Linda B. White, M.D. is the coauthor of Kids, Herbs, & Health (Interweave, 1998) and The Herbal Drugstore (Rodale, 2000).
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