Quick: What’s your total cholesterol number? Twenty years ago, few people knew. But today, you can probably rattle off your number as automatically as your height. Almost everyone who cares about health knows that high total cholesterol—greater than 240 milligrams per deciliter (mg/dl) of blood—is a major risk factor for heart attack. But perhaps not everyone knows that cholesterol should be kept below 200 mg/dl. Friends compare numbers. Doctors routinely check cholesterol, and if it’s high, they are quick to recommend a low-fat diet and prescribe cholesterol-lowering medications. Advertisements tout cholesterol-free foods and foods that help reduce it, notably oat bran and soy.
So what more is there to say? Plenty. The latest research shows that high cholesterol is more hazardous than previously believed. Fortunately, scientists have identified more herbal, nondrug approaches to controlling it than ever.
Cholesterol is a waxy compound with a nasty reputation. But it’s not all bad. In fact, without it, the body can’t make cell membranes, sex hormones and the bile acids that help digest fats. But it takes only a little cholesterol—very little—to meet all of the body’s needs, and the liver can make all that’s necessary. As soon as you start eating foods that contain cholesterol, you risk getting too much and developing cholesterol-related illnesses, notably heart disease and stroke, which together account for one-third of the deaths in the United States.
The red-flag foods are animal products such as meats, egg yolks and whole-milk dairy products. (In addition, heredity makes some people’s livers overproduce cholesterol, a condition called familial hypercholesterolemia.)
Scientists have identified two forms of cholesterol-carrying proteins that ride into the bloodstream. Low-density lipoprotein (LDL) cholesterol, or the “bad” cholesterol, gets incorporated into deposits (plaques) that develop along artery walls. As plaques grow, they narrow the arteries, causing atherosclerosis, or “hardening of the arteries.” As a result, blood flow becomes limited, boosting the risk of heart attack, stroke, and many other conditions: high blood pressure, congestive heart failure, intermittent claudication (atherosclerotic leg pain), and even impotence. Meanwhile, high-density lipoprotein (HDL) cholesterol, or the “good” cholesterol, plucks LDL from the blood and returns it to the liver for elimination.
According to the National Cholesterol Education Program of the National Institutes of Health, total cholesterol should be no higher than 200 mg/dl, LDL should be kept below 160, and HDL above 35. Recently, however, studies have shown that the risk for heart attack and stroke begins to rise at total cholesterol levels well below 200. Increasingly, health experts recommend keeping it below 180. As a result, doctors have become more aggressive about treating high cholesterol. And no wonder. According to the American Heart Association, almost half of American adults have cholesterol levels over 200, and 18 percent—some 40 million people—are above 240.
Reducing total cholesterol—or changing the LDL/HDL ratio toward lowering LDL and raising HDL numbers—has a big impact on heart-attack risk. Every 1 percent drop in total cholesterol cuts heart-attack risk 2 percent while every 1 percent increase in HDL cholesterol reduces risk 3 to 4 percent.
Cholesterol can be reduced in two ways—lifestyle changes or drugs. Doctors recommend both but gravitate toward the latter, notably the “statin” drugs. But cholesterol medication is expensive and can cause annoying, potentially serious side effects. The lifestyle approach is safer and cheaper—and often equally effective.
Eat less animal fat
The fundamental lifestyle approach is a diet low in animal (saturated) fat. Cholesterol itself is not fat. But where there’s cholesterol, there’s also animal fat, so reducing the latter cuts the former. An Oxford University epidemiologist analyzed 395 studies of dietary fat’s effects on cholesterol. His conclusion: Replacing half to two-thirds of dietary animal fat with vegetable fats, such as olive oil, reduces total cholesterol 10 to 15 percent, meaning that heart-attack risk falls 20 to 30 percent.
“The guidelines for a cholesterol-lowering diet are simple,” says Joseph Pizzorno, N.D., former president of Bastyr University, the naturopathic medical school near Seattle. “Eat fewer animal products and more plant foods—fruits, vegetables, grains, and beans.”
However, don’t replace meats with cheese, experts warn. Unless they’re nonfat, dairy foods contain lots of fat and cholesterol. Speaking of dairy, butter is also high in fat and cholesterol. For years, it was believed that replacing butter with margarine was heart smart. But recent research shows that margarine is high in trans-fatty acids, which raise LDL, lower HDL and may even increase the risk of some cancers. Whenever possible, use olive oil instead of butter or margarine.
“In Mediterranean countries, people don’t butter bread,” says Anne Simons, M.D., assistant clinical professor of family and community medicine at the University of California, San Francisco. “They dip it in olive oil. My family does the same. We also cook with olive oil and brush it on corn on the cob.”
Oat bran and soy: Helpful, but not the whole story
The Quaker Oats Company got very lucky in the late 1980s when a highly publicized study showed that eating oat bran (Avena sativa), a soluble fiber in oatmeal, cut cholesterol by spurring its elimination. Subsequent studies confirmed this effect. University of Minnesota researchers analyzed ten studies and found that if total cholesterol is 230 or higher, a daily bowl of oatmeal (without high-fat toppings) can knock cholesterol down 7 percent, for a 14 percent reduction in heart-attack risk. Since then, oatmeal has become a health food, along with oat bran breads, muffins—you name it.
For moderately high cholesterol (200 to 240 mg/dl), 2 oz. of soy protein daily (the kind found in tofu and other soy foods) can reduce total cholesterol about 9 percent and LDL 13 percent. For very high cholesterol (above 300 mg/dl), the same amount of soy knocks it down 20 percent. But for cholesterol levels below 200, the soy effect drops to only 3 percent. These findings come from a University of Kentucky study that used sophisticated statistical methods (meta-analysis) to combine the results of thirty-eight soy-food studies. Like oat bran, soy has become a “heart-healthy food.”
Oat bran and soy are great . . . if you like them.
“But, despite hype from oat bran and soy promoters, there is no evidence that these foods possess some magic power to lower cholesterol,” says James Duke, Ph.D., former chief medicinal herbalist for the U.S. Department of Agriculture. “All plant foods lower cholesterol. The specific fiber in oat bran is beta-glucans. But oats are not the richest source. Barley contains up to three times as much. If you don’t like oatmeal, try a barley soup. And all beans, not just soy, help lower cholesterol. If you hate tofu, make bean soups and salads. Better yet, eat as close to a vegetarian diet as you can.”
Dozens of studies have demonstrated that garlic (Allium sativum) lowers cholesterol. New York researchers analyzed five rigorous studies and determined that consuming “one clove a day decreased total cholesterol by about 9 percent.” Australian researchers analyzed sixteen studies and found that after one month, compared with placebo treatment, five to ten garlic cloves a day cut cholesterol 12 percent. Other studies show that for moderately elevated cholesterol (around 220), two to three cloves a day reduce total cholesterol 5 to 10 percent. A few studies have shown little or no cholesterol lowering with garlic, but the weight of the evidence supports the herb. (However, garlic is also an anticoagulant. Don’t use it if you have a clotting disorder, are taking anticoagulant medication, or are about to have surgery.)
“For cholesterol control,” says Alan Brauer, M.D., a Palo Alto, California-based physician who combines mainstream and complementary medicine, “the more garlic, the better.” Just be sure to choose garlic recipes low in fat and not smothered in meats, cheeses, and cream, he says.
How much garlic lowers cholesterol? The studies have used one to ten cloves a day. Commission E, the German expert panel that monitors the safety and effectiveness of herbal medicines for that nation’s counterpart of the U.S. Food and Drug Administration, recommends 4 g of fresh garlic a day, or two to four cloves.
Unfortunately, that much causes garlic breath. The offending compound, allicin, is the same one that cuts cholesterol. Many supplement companies have developed “odorless” garlic by removing the allicin and substituting its less aromatic relative, alliin. The body then converts alliin into allicin. Pizzorno says that odorless garlic provides the same cholesterol benefits as fresh garlic. A recent Russian study agrees. Among men with heart disease, a deodorized garlic (from Kwai brand, one 300-mg tablet per day) produced “significantly lower” cholesterol in three weeks.
Garlic is a great cholesterol-cutter, but it’s not the only helpful herb. Ever heard of psyllium (Plantago spp.)? How about Metamucil, the bulk-forming laxative? Psyllium (pronounced silly-um), a seed rich in soluble fiber that helps lower cholesterol, is the product’s main ingredient. At the University of Kentucky, 248 people whose average cholesterol level was 229 ate the American Heart Association’s low-fat diet. Some also took 5 g of psyllium (1 tablespoon of Metamucil) twice a day. Six months later, average cholesterol in the diet-only group fell 4 percent, but in the diet-psyllium group, it dropped 10 percent. The higher the participants’ initial cholesterol, the better psyllium worked, lowering those with the highest initial cholesterol levels 25 percent. Simons recommends 1 tablespoon of Metamucil three times a day at mealtimes, along with plenty of water.
Another soluble-fiber-rich seed, fenugreek (Trigonella foenum-graecum), also helps control cholesterol. Indian researchers measured cholesterol levels of sixty diabetics, then asked the participants to have a bowl of soup containing about 1 ounce of powdered fenugreek before lunch and dinner. After twenty-four weeks, the participants’ average total cholesterol fell 14 percent, LDL declined 15 percent, and HDL rose 10 percent. Those with the highest cholesterol levels initially showed even greater benefit. Fenugreek tastes like an odd combination of bitter celery and maple syrup. If you like it, why not add it to soups and sauces, or munch the seeds as the Indians do?
Finally, an Ayurvedic herb also may help. Guggul (Commiphora mukul), an extract of the Indian mukul myrrh tree, contains a compound (guggulsterone) that lowers cholesterol by increasing liver breakdown of LDL. A few studies suggest that after several months, guggul can cut total cholesterol about 20 percent, shave 30 percent off LDL, and raise HDL 18 percent. Pizzorno recommends 500 mg three times a day of preparations containing 25 mg of guggul per pill. Guggul is available at some health-food stores and supplement shops.
The fish factor
Saturated fat raises cholesterol, but interestingly, fat from salmon and other cold-water fish (such as halibut, herring and mackerel) helps lower it. The fat in these fish is high in omega-3 fatty acids, which cut cholesterol. Omega-3 benefits were discovered in the 1970s in studies of Greenlanders. Despite a high-fat diet, they developed little heart disease. The reason? Most of their fat came from fish high in omega-3s.
Since then, a great deal of research has shown that eating cold-water fish lowers cholesterol—and more importantly, cuts deaths from heart disease. Welsh researchers studied 2,000 men with heart disease. Independent of other risk factors, compared with those who ate no fish, men who ate two fish meals a week had 39 percent fewer heart-disease deaths. Harvard researchers analyzed eleven years of data from the Physicians’ Health Study, an ongoing investigation of the diet, lifestyle and health of 20,500 middle-aged male doctors. Compared with participants who rarely ate fish, those who ate it at least once a week had only half the death rate—not just from heart disease, but from all causes.
The American Heart Association “encourages the consumption of fish as both a good source of protein low in saturated fat and an excellent source of omega-3 fatty acids.” For cholesterol control and general heart health, Simons suggests one or two salmon meals a week. Keep it lowfat by broiling, baking or steaming—again, skip the butter and cream.
Supplements also help
Hate garlic? Try garlic capsules. Despise tofu? Take a soy supplement. Don’t care for cold-water fish? Get your omega-3s in capsules—fish oil or flaxseed oil. It’s easier to use flaxseed oil because the effective dose is just 1 tablespoon a day, according to Seattle-based naturopath Michael Murray. If you use fish oil, you have to take a great deal more.
Another cholesterol-lowering supplement is niacin (vitamin B3). Melvyn Werbach, M.D., assistant clinical professor at the University of California, Los Angeles School of Medicine, and author of Nutritional Influences on Illness (Third Line 1996), says, “Niacin is so well-established that before today’s cholesterol-lowering drugs, it was the treatment of choice.”
New York City clinical nutritionist Shari Lieberman, Ph.D., says that niacin is “especially useful for people like me, who have a stubborn hereditary predisposition to high cholesterol. Using diet and exercise, I was able to lower mine from 270 to 245. But adding niacin, my cholesterol stays at or below 200.”
Niacin reduces liver production of LDL cholesterol. In a study of 136 people with high cholesterol, researchers at the Oregon Health Sciences University pitted niacin (1.5 g per day) head-to-head against a popular—and more expensive—drug (lovastatin, 20 mg per day). After twenty-six weeks, niacin produced very similar results.
Multivitamins contain niacin, but not enough to lower cholesterol. The dose required is anywhere from 250 to 3,000 mg a day. If you decide to try it, be sure to start with a low dose, working up to a higher dose under the supervision of a health-care practitioner. At high doses, niacin may cause “flushing,” a sudden feeling of heat and discomfort similar to a menopausal hot flash. As a result, many people who try niacin stop using it, and few mainstream doctors prescribe it.
“Flushing can be a problem,” says Michael Criqui, M.D., a professor of family and preventive medicine at the University of California, San Diego Medical Center, “but you can minimize it by starting with a low dose and increasing it slowly, or by taking an aspirin shortly before taking niacin.” Niacin flush is caused by certain compounds in the body, called prostaglandins. Aspirin has an anti-prostaglandin effect, Criqui says.
In addition to flushing, cholesterol-lowering doses of niacin may also cause intestinal distress, gout, and liver damage. People who have gout or liver disease should not take it. If you use niacin, especially the sustained-release variety, Pizzorno advises having a liver-function test every three months.
Finally, consider pantethine (a form of pantothenic acid), a member of the B vitamin family that helps the body digest fats. It also interferes with cholesterol synthesis in the liver. At the University of Bologna, Italy, researchers gave pantethine to people with high cholesterol. In eight weeks, it lowered total cholesterol and LDL 14 percent, and raised HDL 10 percent—without side effects. Lieberman recommends the dose used in the study—300 mg three times a day. Pantethine is available at most health-food stores.
Exercise: Walk away from high cholesterol
At the Cooper Institute for Aerobics Research in Dallas, researchers divided 102 out-of-shape women into four groups. One group stayed on the couch. The other three groups walked about three miles a day, five days a week, for six months, at paces ranging from slow strolling to brisk aerobic walking. The sedentary group experienced no cholesterol decrease, but all of the walkers did, even the slow strollers. In fact, their improvements were surprisingly similar to those who walked faster. Their total cholesterol fell 2 percent, their LDL dropped 4 percent, and their HDL rose 6 percent. The researchers concluded that “vigorous exercise is not necessary [to] obtain meaningful improvement” in cholesterol levels.
Any type of exercise improves your cholesterol profile, according to William Haskell, Ph.D., a professor of medicine at Stanford University. It’s especially good for shifting your LDL-HDL balance—lowering levels of bad LDL and raising levels of good HDL, he says.
Drugs work best when combined with natural approaches
Today’s most popular cholesterol medications are the “statin” drugs: lovastatin (Mevacor), simvastatin (Zocor), pravastatin (Pravachol) and fluvastatin (Lescol). They’re so effective that people taking them might be tempted to forget about other approaches. Big mistake. Researchers at the University of California, Los Angeles, placed ninety-three people taking a statin drug on the ultra-low-fat Pritikin diet, along with enrollment in a medically supervised exercise class. On the statin drugs alone, their total cholesterol averaged 220. But the drug-lifestyle combination cut it to 180. Start with lifestyle, herbal, and natural approaches, Simons says. If your cholesterol remains high, add medication, but don’t abandon nondrug treatments.
Alcohol and the French Paradox reconsidered
Alcoholism is a major public health problem and a risk factor for heart disease and several cancers, not to mention the cause of myriad family problems and motor-vehicle accidents. But there’s another side to the alcohol story—dozens of studies showing that moderate drinking helps prevent heart disease.
“Moderate drinking” means one drink a day. A “drink” is one standard beer (12 oz.), one shot glass of liquor (1.5 oz.), or a standard wineglass about half-full (5 oz.).
When population studies first showed that light-to-moderate drinkers had a lower death rate from heart disease than heavier drinkers or abstainers, scientists came up with a good explanation: Alcohol raises HDL cholesterol. This partly explained the French Paradox, the fact that the French eat a fairly high-fat diet but have a much lower rate of heart disease than Americans. But higher HDL alone did not explain the French Paradox.
The French love red wine. Scientists discovered that the pigments in red grape skins are potent antioxidants that help control—and even reverse—the cell damage that underlies heart disease. But you don’t have to consume alcohol to get many of the benefits of red wine. Purple grape juice has all the antioxidants found in red wine. It, too, reduces the risk of heart disease.
And there’s more to the French Paradox than red wine. Compared with Americans, the French consume less meat and more fruits, vegetables and fish. In other words, they have a heart-healthier diet.
Health experts agree that a little alcohol doesn’t substitute for the many nonalcoholic ways to reduce cholesterol. They also agree that no one should drink for health who is alcoholic or has a history of alcoholism, binge drinking or any arrests for drunk driving. In addition, even moderate drinking appears to increase risk of breast cancer. Women should discuss their risks for heart disease and breast cancer with their physicians before using alcohol to control cholesterol.
My favorite cholesterol- lowering cookbook
Heart disease researcher Ron Goor, Ph.D., of Bethesda, Maryland, cut his cholesterol from a dangerously high 311 mg/dl to 200 largely through recipe modifications developed by his wife, Nancy. The Goors went on to publish a bestselling series of low-fat, low-cholesterol cookbooks, Eater’s Choice (Houghton Mifflin). My wife and I cook from the Goors’ books regularly. The recipes are tasty, easy to prepare, and use common ingredients.
An apple a day
Apple pulp is rich in the soluble fiber pectin. Over several months, an apple a day can cut total cholesterol around 5 percent, naturopath Joseph Pizzorno notes, which reduces heart-attack risk 10 percent. Other good sources of pectin include carrots, pears, oranges and grapefruit. Pectin is also available as a supplement.
San Francisco-based health writer Michael Castleman is the author of ten books, most recently The New Healing Herbs (Rodale, 2001), an updated edition of his million-selling guide to herbal medicine. At last check, his total cholesterol was 178.