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Cholesterol

Blood Fats: too much of a good thing

Cholesterol is a lipid. Lipid is another name for fat, which is an essential component for the healthy functioning of plants and animals.  Cholesterol is an essential lipid for our bodies. It is used in cell membrane maintenance. It is a precursor to Vitamin D, which is made in the skin with sun light exposure. It is the precursor to many of the hormones of our body including the sex hormones such as estrogen and testosterone and adrenal hormones such as cortisol. Cholesterol is so important that our bodies do not rely on cholesterol from food sources alone. We actually manufacture about two-thirds of the cholesterol that we use. This is done in the liver. Cholesterol is derived from other fats in our bodies. These fats are either ingested or manufactured. Saturated fat stimulates cholesterol production and over-production.
 
Cholesterol is in the shape of a ring. Triglycerides, the other major fat in the body, are in the shape of a chain. These fats are transported in the blood in lipoproteins. These are sphere shaped bodies that consist of the fat (which is not water soluble) and protein (which is water soluble). It is the water solubility of the lipoprotein structure that allows for transport in the blood. The lipoproteins are categorized according to size. Chylomicrons are the largest in size and the lowest in density. There are also very low density lipoproteins (VLDL), low-density lipoproteins (LDL) and high-density lipoproteins (HDL). There are other lipid and non-lipid molecules that are significant in the development of arteriosclerosis. These include lipoprotein (a), apolipoprotien B, homocysteine and fibrinogen.
 
Low Density Lipoprotein (LDL) plays a major role in atherosclerosis (the process by which our arteries age and become occluded). LDL in is not inherently dangerous. It transports about 75% of the cholesterol to the body’s cells. Remember, cholesterol is an important building block for our hormones and cell membranes.  If LDL becomes oxidized, however, it can produce inflammation in the lining of our arteries. This results in atherosclerosis. Oxidation is another normal process in our body. However, when it becomes imbalanced it can produce an excess of reactive molecules that cause inflammation. This triggers white blood cells to gather at the site of inflammation. They form a fatty substance called plaque; the first step in atherosclerosis.  As plaque builds up, the arterial wall becomes stiff and narrowed and blood flow is restricted. This process contributes to heart attack and stroke. Factors that can cause an increase in oxidation and subsequent inflammation include excessively high cholesterol and LDL cholesterol levels, stress, poisons (tobacco), allergens (including food sensitivities) and infections and metabolic abnormalities like diabetes and insulin resistance leading to excess insulin production.  It is desirable to keep cholesterol and LDL as low as possible and minimize oxidative stress in our bodies. The size of the LDL particle is an important factor in the promotion of arteriosclerosis. Small Dense LDL particles are associated with an increased risk to arteriosclerosis. Larger LDL particles are not as likely to promote arteriosclerosis. This is a relatively new concept and its ultimate relevance in the promotion of arteriosclerosis is being debated in the medical literature.
 
High Density Lipoprotein (HDL) is important in preventing atherosclerosis. HDL helps to remove excess cholesterol from the walls of the arteries and return it to the liver. Levels above 45 are considered protective. Levels below 35 are associated with an increased risk to heart attack and stroke. HDL size is also relevant to its ability to prevent the development of atherosclerosis.
 
Triglycerides are chain type fats whereas cholesterol is a ring type fat. Triglycerides are important building blocks for the cell membrane and other specialized fats. High levels are considered dangerous. They are associated with an increased risk of atherosclerosis, stroke and diabetes. It is desirable to keep triglyceride levels below 150.

Guidelines:

LDL Cholesterol is the primary target of therapy. There are numerous studies in the medical literature that support the idea that high levels of LDL Cholesterol are related to an increased risk in coronary artery disease, stroke and other chronic degenerative diseases of aging.
 
LDL Cholesterol

100

values of 100 or less are considered optimal. In people with existing coronary artery disease, stroke or diabetes the goal LDL value is 70 or less.

100-120     

these are acceptable values in people with no other risk factors

130-159

these are excessive values and efforts to lower them should be undertaken with diet and non-prescription supplements

130-159

these are excessive values and efforts to lower them should be undertaken with diet and non-prescription supplements

160-189

these are high levels and should be treated with diet non-prescription supplements and prescription medication

>190 

these are dangerous levels and should be treated with diet, non-prescription supplements and prescription medications.


Total Cholesterol

<200

values less than 200 are considered optimal

200-239     

values in this range are borderline high and efforts to lower cholesterol via diet and non-prescription supplements is recommended

>240

values in this range are high and efforts to lower cholesterol with diet, non-prescription supplements and prescription medications is recommended


HDL Cholesterol

<40             

values in this range are considered undesirable and efforts to raise HDL are recommended


Major Risk Factors that Modify LDL Goals:

  • Cigarette smoking
  • Prior episodes of heart attack and/or stroke
  • Hypertension (characterized by a systolic BP greater than 140 and/or a diastolic BP greater than 90
  • Low HDL cholesterol (less than 40)
  • Family history of premature CHD
  • Age (men > 45; women>55)
  • Insulin resistance and/or diabetes
  • From an anti-aging medicine view point, the lower the cholesterol and LDL and the higher the HDL the better. Simply stated, you would like your cholesterol, LDL and HDL to look like the best values of a younger person.

Consequences of high cholesterol, high LDL, high Triglycerides and low HDL:

Coronary Heart Disease is still the leading cause of death in the United States. Half of the patients with coronary heart disease have high cholesterol and LDL as an important contributing factor. Every time a person’s cholesterol level drops by a point the risk of heart attack drops by 2%. The younger a person is when first diagnosed with high cholesterol the more significant high cholesterol is to their risk of heart disease. Other factors are also important; these include: smoking, high blood pressure, insulin resistance, diabetes, heavy metal burden, blood viscosity and stress. Forty percent of people with high cholesterol do not develop serious heart problems. This simple fact speaks to the complexity of assessing risk and the need to individualize a risk reduction program.

Stroke risk may be less dependent on high levels of cholesterol and LDL and more dependent on low levels of HDL. In this case I think that the amount of oxidized LDL is an important factor, however, we do not commonly test for this. We can, however, do tests that measure oxidative stress in the body in general (Spectracell analysis).

Insulin Resistance is a phenomenon whereby a person makes an adequate amount of insulin but their cells are not as sensitive to the insulin message as they should be. It has been observed that a high level of triglyceride and low HDL is associated with insulin resistance. I think that the lipid abnormalities are caused by the underlying problem of insulin resistance. When we do routine blood screening and we see this pattern of lipid abnormality we can suspect insulin resistance. This will guide therapy in terms of diet and supplements that improve insulin resistance.

The Effect of Age and Sex on Cholesterol Levels

More than half of adults have a total cholesterol over 200. Twenty percent have levels greater than 240. This is due to our diet. In other cultures, where dietary fat is low and dietary fiber is high, cholesterol levels are much lower.  In general, cholesterol levels are lower when we are younger and increase when we are adults. Sex differences are notable in that HDL is higher in menstruating women than in men. This difference decreases after menopause. The significance of high cholesterol in healthy elderly is a matter of debate. The weight of recent evidence supports the idea of lowering cholesterol to optimal levels regardless of age. . The debate in this area is ongoing and in general the decision to attempt to lower cholesterol should be individualized. What is not controversial is the desirability of high HDL levels at any age.

Strategies for lowering Cholesterol, LDL and Triglycerides

The Role of Lifestyle Modification

Modest lowering of cholesterol, LDL and Triglycerides will produce a substantial reduction in risk to arteriosclerosis, heart disease and cerebrovascular disease. Lifestyle modification is the first step as it is often adequate to achieve the desired results.

Diet

A diet that consists of 20-30% fat, 20-30% protein and 50-70% carbohydrate will lower cholesterol and LDL by 10-15%. The variations are dependent on the individual. Why can some people do an “Atkins” type diet, which is very high in fat and lower their cholesterol? Not only do they lower their cholesterol but they lose weight and feel well. Still others do well on a “Dean Ornish” type diet. This is a very restricted fat diet. Some people thrive on it. They lower their cholesterol and feel great. I believe that we have different dietary needs and these needs must be individualized for any person to experience benefit without feeling deprived. One size does not fit all. Perhaps those that do well on the “Atkins” type diet have underlying insulin resistance and must minimize intake of the starchy carbohydrates to optimize their metabolic profiles
Some dietary recommendations have value regardless of your individual needs. In general refined foods are not desirable. The first broad categories of refined foods are those with refined sugar in them. Candy, dairy deserts, pastries, soft drinks, sugar added to coffee or tea constitutes the main sub categories. The second broad categories are foods high in refined carbohydrates. These include bread, rice, pasta and potatoes. Other highly processed foods in this category include pretzels, potato chips, corn chips and party mixes. This does not mean you should not eat any bread, rice, pasta or potatoes. It means that they should not be the staple of your diet. Rather they should be eaten more like a condiment; in smaller portions. When you do eat these foods make sure they are unrefined (brown rice, whole grain bread, baked potato) or appropriately cooked (al dente pasta). The third broad category of foods to minimize or avoid are those high in saturated fats. Red meats, fried foods and most processed foods fall in to this category. If you are going to eat red meat look for organic free-range meat. Avoid red meat from feed lot fed animals. Trans fats are a type of fat that is “designed” by food processors to increase shelf life of packaged products. They are dangerous and should be avoided.  Some fats provide health benefits when used in moderation. The monounsaturated fat from olive oil is one. The polyunsaturated fats from deep sea fish, nuts and seeds are another.

So what should you emphasize in your diet? Again, it should be individualized. Generally speaking you want to emphasize unprocessed foods such as whole grains, organic fruits, vegetables, nuts and seeds. If you are going to eat fish look for deep sea fish such as wild salmon, tuna and halibut. If you are going to eat poultry or meat look for organically raised, free range products. The quality of the fat from animals raised in this way is much healthier for us.

Modest calorie restriction to achieve a healthy weight is desirable. Excess weight may interfere with the benefit from some class of medications used to lower cholesterol (the statin drugs such as Zocor, Lipitor, Crestor and Pravachol).

What we drink matters also

Adequate hydration is an important, simple and inexpensive way to optimize our health. One study noted that men who drank 5 or more glasses of water per day had half the heart attack and stroke incidence of men who drank two or less glasses of water per day.

Alcohol, in moderation, may raise HDL cholesterol. Unfortunately, it is almost impossible to lose weight and drink alcohol. Pregnant women and those at risk for alcohol abuse should not drink alcohol.

Drug Therapies for Lowering Cholesterol

Statin Drugs

 

HMG CoA reductase inhibitors are often referred to as statin drugs. They inhibit a key enzyme that controls the rate of cholesterol production. They also may increase the ability of the liver to remove LDL cholesterol from the body. Recently evidence is accumulating that this family of drugs exhibits anti-oxidant and anti-inflammatory properties that protect from heart disease and stroke independently of their cholesterol lowering effect.  This family of drugs has been show to interfere with the production of Coenzyme Q 10. This is an important metabolic intermediary and antioxidant. I recommend that patients taking statins supplement with 100 mgs of CoQ10 one or two times per day.

Some patients experience muscle aches and fatigue when using statins, making continuous use problematic. The use of CoQ10 supplementation will prevent these side effects. When taking this class of drugs I recommend that liver function tests be checked at 3-6 month intervals.

Statin medications commonly prescribed include atorvastatin (Lipitor),  rosuvastatin (Crestor) and simvastatin (Zocor). Recent studies with Crestor have shown that aggressive lowering of cholesterol and LDL can cause regression of atherosclerotic plaque. Studies with Lipitor have shown that lowering the cholesterol and LDL can reduce the risk of stroke by 50%.

Drugs that act on the gastrointestinal tract to lower cholesterol and LDL

Ezetimibe (Zetia) inhibits cholesterol reabsorption from the small intestine. Dietary cholesterol absorption can be inhibited by this medication. It can account for a 10-15% reduction in cholesterol and LDL. This medication is does not have any systemic effects. It works only on the lining of the small intestine.

Colesevelam (Welchol) inhibits the reabsorption of bile acids by the small intestine. Our body makes bile acids from cholesterol. When the bile acids are depleted we use our cholesterol to make more bile acids. This results in a lowering of cholesterol. Bile acids are important for digestion of fat. We reabsorb them from the small intestine. Welchol binds to the bile acids so they can not be reabsorbed and are excreted in the feces. Welchol has no systemic side effects. In some patients, it can cause constipation.

Fibric Acid Derivatives

Fibrates are another class of medication used to lower cholesterol. They are typically used when triglycerides are the primary lipid that is elevated while cholesterol is the secondary one. Fibrates can increase HDL as well. Gemfibrozil (Lopid) and fenofibrate (Tricor) are the two medications used in this category. Side effects include muscle aching, sun sensitivity, skin rash and gastrointestinal disturbance. This class of drugs can interact with other medications such as statin drugs, Coumadin, some antibiotics, some Diabetes medications and grapefruit juice.

An Integrated Approach

I am always looking for ways of helping patients achieve an optimal lipid profile. This means achieving safe levels of cholesterol, LDL and triglycerides, maximizing HDL and protecting from LDL cholesterol oxidation.

I am not against prescription drugs to help patients accomplish their goal. The problem is that the individual often uses the medicine and makes no other changes in diet, exercise patterns or stress reduction. Nevertheless, I do not hesitate to prescribe medications to lower cholesterol while encouraging patients to modify lifestyle and use supplements that decrease the potential side effects of prescription drugs or improve their benefit.

Complimentary and Alternative Medicine Strategies:

Diet: Diets low in saturated fat (animal products), low in sugar and high in fiber are the key. Unprocessed foods are important (See our diet information section). What is the point of taking supplements or even drugs if you are going to injure yourself by eating poorly?

Exercise: You do not have to run marathons. Regular long slow distance activities are the key. Activity is the key!  Gardening, walking, cycling and swimming are all good activities. You can do short amounts of activity throughout the day. Won’t it be interesting when the hard-to-find parking spaces are the furthest away? Twenty to sixty minutes of cumulative activity per day is desirable (remember, it does not have to be done all at one time).

Artichoke leaf extract: Artichoke leaf extract has been shown to lower cholesterol in clinical trials. It is useful as part of a combination therapy protocol in lowering cholesterol and LDL.

Garlic: Garlic has been shown to effectively lower serum cholesterol and triglycerides. In addition it can inhibit platelet aggregation. This means that it makes your blood less sticky. It can also increase fibrinolysis. This is another mechanism for decreasing blood stickiness. A therapeutic dose can be obtained from chewing one clove of garlic daily. For those adverse to the taste or odor a supplement with 5,000 micrograms of allicin daily is recommended. Garlic may have the additional benefit of helping to optimize blood pressure.

Curcumin: We know curcumin as a spice called tumeric. Curcumin has been shown to lower cholesterol, LDL and triglycerides. In addition, it can raise HDL.  The recommended dose is 500 mgs. two times per day. Curcumin may be beneficial in preventing the oxidation of LDL. Oxidized LDL is believed to aggravate the arteriosclerotic process. Curcumin can be useful in patients with arthritis.

Fiber:  Water-soluble fiber helps the body to remove bile acids from the intestinal tract. Since bile is made from cholesterol the body uses cholesterol to make more bile. The result is a lowering of cholesterol and LDL.  I often suggest a fiber supplement in addition to a high fiber diet in patients who have elevated cholesterol and LDL cholesterol and chronic gastrointestinal problems such as Irritable Bowel Syndrome, constipation and hemorrhoids.  Herbulk is product high in water-soluble fiber. Each scoop has 6 grams of fiber.  I suggest using it as part of your morning health shake.  

When using a fiber supplement it is important to drink enough water each day (60-80 ounces per day).

Ginger: Ginger is a spice from the same family as curcumin. It has many beneficial properties. It has been shown to lower cholesterol and LDL. In animal models it has been shown to prevent arteriosclerosis. One to two capsules of a ginger extract twice daily can be helpful. Ginger can also be useful in patients with gastrointestinal problems such as gastro-esophageal reflux, nausea and irritable bowel syndrome.

Green Tea: Green tea has been shown to lower cholesterol, LDL and triglycerides. It may also raise HDL. In addition, green tea has potent antioxidants that inhibit LDL oxidation. I recommend green tea as a beverage for those who can tolerate caffeine. Teaflavin is a green tea extract. It was subjected to a double blind study that was published in a peer reviewed medical journal. One capsule daily lowered cholesterol and LDL by 10%. I usually recommend one capsule two times per day with meals.

Gugulipid: Gugulipid is made from the resin of the commiphora mukul tree of India. Gugulipid has been part of traditional Indian medicine for centuries. Gugulipid has been shown to reduce cholesterol and LDL while raising HDL. The therapeutic dosage of Gugulipid is based on guggulsterone content. The recommended dose is 25 mg of guggulsterones three times per day. You must read the label to make sure you are getting the appropriate dose of guggulsterones.

Niacin: Niacin is a cross over nutritional product. In low doses it is a vitamin. In high doses it is a medication that lowers cholesterol, LDL, triglyceride and lipoprotein (a), while raising HDL. The dose of niacin (not niacinamide) which has this therapeutic effect is 1000-3000 mgs per day. Achieving adequate doses with regular niacin is difficult because it causes severe flushing. Slow release niacin is available as a nutritional supplement (Niavasc) and a prescription medication (Niaspan). These forms are more tolerable.  Taking aspirin about 1 hour before taking niacin will decrease the chance of flushing . Infrequently, niacin in high doses can raise liver enzymes. I recommend checking the lipid profile and liver enzymes at four to six month intervals.  Niacin has been shown to decrease fibrinogen. Elevated fibrinogen levels are a mark of underlying inflammation and another risk factor for heart attack.

We have recently discovered that niacin therapy can raise homocysteine levels in some individuals. I recommend checking homocysteine in patients taking niacin in large doses. Homocysteine is a metabolic byproduct that can cause arteriosclerosis when elevated.

Pantothine: is a derivative of Pantothenic Acid. It has been shown to lower cholesterol and LDL cholesterol and raise HDL cholesterol.

Plant Sterols: Phytosterols are plant-based molecules found in grains, nuts, seeds and vegetable oils. They have been shown to lower cholesterol by inhibiting absorption of dietary cholesterol. This effect has been demonstrated in double blind placebo controlled studies published in peer reviewed medical journals. Phytosterols have been shown to improve immune function. They have also been shown to improve prostate and colon health. The recommended dose is two capsules three times per day with meals. This is a product with multiple health benefits. It may help optimize immune function and minimize the adverse effects of hormones in the body. I use a product called Cholestepure in a dose of 2 capsules three times per day with meals.

Policosanol: Policosanol is a derivative of sugar that has been shown to lower total cholesterol and LDL cholesterol while raising HDL. It is available over the counter. The recommended dose is 10 mgs taken twice daily with meals. To date, no adverse effects or drug interactions have been noted. Recent controlled studies have failed to show a benefit for policosanol. I have not found it effective in my experience with patients. I am no longer recommending it.

Red Rice Yeast: This is a product used in traditional Chinese medicine. It has been found to have cholesterol-lowering properties. This product has statin drug precursors and statins were derived from it. When using this supplement, I recommend that a physician follow the individual and that liver function tests be checked at four to six month intervals.
 

Combination Products:

Cho-less is a combination product that was created by master herbalist Donald Yance.

It combines Bulgarian Red Yeast, Artichoke leaf, Pantethine, Guggulipid, Beta-Sitosterol, Niacin and Policosanol. The quality of the products is very good. The dose is 2-3 capsules two to three times per day. It appears to be a promising product for reduction of total cholesterol and LDL.

Each person must create a unique program to optimize the blood fats. This is based on factors from the individuals’ history, family history, life style factors and lab data. It is more important to optimize the lipid profile than to adhere to a dogma: “I only want to do it naturally.” Working with a knowledgeable practitioner is very helpful. The adverse effect of certain prescription medication may be offset by appropriate supplementation. The non-prescription products may have adverse effects. There is no one size fits all solution. The most important issues:

  1. 1. A diet appropriate to the individuals’ unique metabolism, food tolerances and life style.
  2. An exercise program that allows the individual to achieve 1,200 to 1,600 calories of aerobic energy expenditure per week.
  3. The willingness to work at creating and maintaining the attributes of a meaningful life.
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