Cholesterol and Lipid Management

salmon sushi

Cholesterol is a wax-like fatty substance produced in the liver and found in many foods we eat. Particles of cholesterol called lipoproteins are combinations of fat and proteins that travel in the blood and are essential for life. The paradox of cholesterol is that it can be both friend and foe.  Cholesterol is required for all repair mechanisms in the body, cholesterol also insulates our nerves, makes up cell membranes, and helps to produce certain sex hormones.

Even though the body has a protective feedback mechanism that ensures that a decrease in the production of cholesterol from the liver will occur if we consume an abundance of cholesterol-containing foods, eventually excess cholesterol causes a buildup on blood vessel walls, increasing the risk of coronary artery disease and arteriosclerosis.

Elevated cholesterol is one of the most common “modern” diseases known in the industrialized world. Estimates are that well over 50% of the total American and European populations have total cholesterol levels over 200 mg/dL, and about 25% have levels of 250 or above. Although fat and cholesterol are not the same, treatments can be similar for both. Antioxidants can inhibit cholesterol from oxidizing the linings of the arteries (also caused by high sugar intake). Controlling your cholesterol level is still an important step in preventing heart disease. The goal of drugs and/or supplements is to regulate the production of HMG-CoA reductase, an enzyme in the liver that produces cholesterol. However, statin drugs (and red rice yeast) that significantly block this enzyme also block the CoQ10 enzyme that has a direct, positive effect on the energy part of the heart cell. Thus, CoQ10 should be supplemented by all individuals taking statin drugs or red rice yeast.

Concentrated in the liver, blood, and brain, cholesterol is the most abundant steroid in animal tissue. It is the precursor to cortisol, bile acids in the liver, and reproductive hormones. Cholesterol is a major structural component of all cell membranes and a free-radical scavenger (an anti-cancer agent). About 60-80% of circulating cholesterol is synthesized in the liver and intestines, while 20-25% comes from dietary sources. 

TYPES OF CHOLESTEROL

Low Density Lipoprotein (LDL) 

Considered the “bad” form of cholesterol, LDL carries most of the cholesterol in the blood to the tissues. The cholesterol from LDL is the main source of damaging accumulation and blockage of the arteries. The more LDL cholesterol you have in your arteries, the greater the risk of plaque buildup which narrows the arteries and makes the heart work harder. If too much plaque accumulates, blood flow and oxygen to the heart are impeded, causing chest pain. If a blood clot forms and obstructs the artery, a heart attack may occur.

High Density Lipoprotein (HDL) 

HDL, the “good” form of cholesterol, normally makes up 20-30% of the total serum cholesterol. HDL picks up and transports cholesterol in the blood back to the liver (where it is made), which leads to its elimination from the body. HDL can keep LDL from building up in the walls of the arteries. High levels of HDL have been shown to be a strong independent inverse predictor of coronary heart disease (CHD).

Triglycerides

Triglycerides are a common form of fat carried through the bloodstream. Most is stored in fat tissue; only a small portion is found in the bloodstream. High blood triglycerides don’t cause arteriosclerosis, but lipoproteins (fats) also contain cholesterol, which can cause arteriosclerosis. Triglyceride levels often fluctuate easily, changing after each meal. Increased levels are almost always a sign of too much carbohydrate and sugar intake. High triglycerides are associated with abnormalities of lipid and carbohydrate (simple sugar) metabolism. High triglyceride levels, along with high LDL (“bad”) cholesterol, are considered strong independent risk factors for cardiovascular disease, leading to heart attack or stroke. Elevation in triglycerides and low levels of HDL are extremely common in patients with obesity, insulin resistance, and Type II diabetes.

The Role of Homocysteine

Homocysteine, an intermediate amino acid formed during the metabolism of methionine, has been shown to be an independent, modifiable risk factor for cardiovascular disease. Plasma homocysteine is normally less than or equal to 12 μmol/L. When elevated, homocysteine can play a role in the development of cardiovascular disease. 

SAFE LIMITS

Triglycerides – Ranges between 50-150 mg/dL are considered normal, although the goal should be below 100 mg/dL. 150-199 is borderline, and over 200 is considered high.

LDL – LDL should be less than 100 mg/dL, while 101-130 is regarded as borderline. 160 and over is considered high.

HDL – HDL should be greater than 40 mg/dL. Below this level puts you at a substantial risk for coronary heart disease. The average for men is 45 mg/dL, and for women about 55 mg/dL. Over 60 mg/dL is desirable.

Total Cholesterol – Less than 200 mg/dL is desirable, while 150 mg/dL is ideal. The borderline range is 200-239, and above 240 is considered high. In some circles it has been verified that people with total cholesterol levels under 150 have never been reported to have a heart attack.

Total cholesterol-to-HDL Ratio – This should be less than 4.5.

LDL cholesterol-to-HDL Ratio – This should be less than 3.0.

DIET

A heart-healthy diet should be considered one of the primary therapeutic lifestyle interventions for patients with any level of risk for coronary heart disease. Simple diet changes can reduce cholesterol by 20 per cent.

Healthy Recommendations

  • The initial alternative approach to lowering total cholesterol is eating a diet that emphasizes fruits and vegetables; fat-free or low-fat dairy products; legumes and nuts; cereal, oats, psyllium, and grain products; and some fish and poultry. Minimize or eliminate simple carbohydrates and animal protein. A plant- or starch-based diet is rich in fiber, and fiber is the leading ingredient in lowering cholesterol the natural way. Fibrous foods include fruits, vegetables, pure vegetable oils, oat bran, legumes (beans), whole grains, rice, nuts, seeds, and garlic. 
  • There is no cholesterol in the plant kingdom. It is easy to mix “fat” content with “cholesterol,” and although it is true that most fatty foods are also high in cholesterol, that is not always the case. The best example is the egg. An egg yolk is a low-fat food, but is extremely high in cholesterol (550 mg/100 gm portion). However, eggs have zero fiber. 
  • The more sugar you consume, the more insulin you secrete, and the more cholesterol the body produces. Processed carbohydrates, such as wheat flour, dry cereals, and corn meal-based products, break down into sugar quickly and trigger more insulin release from the pancreas. More fibrous vegetables and many fruits, especially berries, release their sugar more slowly. 
  • Consuming more cold-water fish such as salmon and cod may lower triglycerides, but have little effect on total cholesterol and HDL. (Avoid tuna, tilefish and shark because of high mercury content). 
  • Soy protein is very effective in lowering LDL cholesterol and triglycerides, with little effect on HDL’s. Soy milk, tofu, meat substitutes and baked goods made with organic soy flour (approx. 25-50 grams daily) are excellent sources of soy protein. 
  • Cut back or eliminate coffee consumption. Drinking decaffeinated and/or regular coffee has been linked to higher cholesterol and higher blood pressure levels. 
  • Lycopenes from tomatoes are healthy sources of antioxidants from plant lignans. Dr. Julian Whitaker reports that eating two medium-sized carrots every day can drop your cholesterol by 50 points in as little as 3 weeks. 
  • Researchers in Israel have found that red grapefruit can help reduce cholesterol in some patients who do not respond to statin drugs.
  • Eating healthy nuts (almonds, Brazil nuts, walnuts) may lower cholesterol. 

RISK FACTORS

What You Eat

Saturated fat from animal foods increases your LDL more than anything in the diet. Cholesterol is found in eggs, meats, shellfish, poultry, and dairy products. Chicken, turkey, and fish have about the same high cholesterol content (albeit lower fat) than pork, beef, or lamb. Choose the right fats from unsaturated oils (olive, canola, soy and flax seed), nuts (almonds significantly lowered LDL), avocados, and cold water fish. Refined carbohydrates (sugars) will increase insulin secretion, and your body will respond by creating more cholesterol. The majority of Americans eat a high processed-carbohydrate diet which leads to unhealthy cholesterol levels and low HDL levels. Avoid refined carbohydrates such as refined sugar, white flour, chocolate, junk food, MSG, aspartame, and excessive dairy products.  Add more soluble fiber (complex carbohydrates) found in beans, oats, and psyllium.  Other soluble fiber foods include whole grains, bran, fruits and vegetables. High cholesterol is commonly associated with individuals suffering from an inability to metabolize both sugar and simple carbohydrates.

Heredity

Since genes can control LDL cholesterol levels, family history cannot be overlooked as a root cause. One form of hereditary high cholesterol is called hypercholesterolemia, which often leads to early cardiac problems.

a grandfather holding his grandchild

Other Diseases

Thyroid dysfunction can have a negative effect on cholesterol in the blood. If the thyroid gland is underactive (hypothyroidism) and producing too little hormone, metabolism can slow, decreasing the body’s ability to metabolize cholesterol and causing an excess of cholesterol in the blood. Huge doses of cholesterol may suppress thyroid function, which can cause atherosclerosis. Diabetes increases the risk of high cholesterol 3-7 times. Attention should also be directed toward individuals with elevated blood pressure and homocysteine levels.

Weight

Excess weight (obesity) will tend to increase LDL cholesterol levels. Anyone with a body-mass-index (BMI) over 30 is considered obese. Weight loss can also help to lower triglycerides and raise HDL.

a group of men, one is overweight and possibly obese

Stress

Long-term stress has been shown to increase cholesterol levels in the blood. Stress frequently affects people’s habits, and the tendency to eat more fatty and processed foods is linked to depression and stressful states. Type “A” people who poorly adapt to stress are at an increased risk of developing elevated cholesterol levels.

How much you eat

In some cases people who eat five or six times a day had lower total cholesterol and LDL, while those you had two large meals had higher measurements.

Exercise

One of the most important means to lower LDL cholesterol and raise HDL cholesterol levels is through physical activity and regular exercise.  Exercise is an excellent way to help keep the heart healthy, knock off a few pounds, and raise the important HDL.

Age and Gender

Before menopause, women generally have lower total cholesterol levels than men the same age. After menopause, women’s total cholesterol levels increase. Age is a secondary factor, with high cholesterol levels often occurring in men over 45 and women over 55.

Alcohol, Caffeine and Smoking

Alcohol intake increases HDL but does not lower LDL cholesterol. Drinking too much alcohol can damage the liver and heart muscle, leading to high blood pressure and higher triglycerides. A recent study from the Fuqua Heart Center in Atlanta, shows that drinking decaffeinated coffee can actually raise a person’s level of LDL cholesterol associated with cardiovascular disease risk. Smoking cigarettes increases the production of endogenous cholesterol and is considered a primary risk for high cholesterol.

Statin Drugs (Lipitor, Zocor, Crestor, Pravachol, Vytorin)

While statin drugs effectively lower total cholesterol, they have been associated with elevated liver enzymes, and sometimes depression. Statin drugs also deplete the body of co-enzyme Q10 levels. 

A note of caution regarding stating drugs: Approximately 30-50 percent of all individuals taking statin drugs for cholesterol are experiencing a side effect known as myalgia (sore and painful muscles anywhere on the body.)  A smaller percentage of patients (up to 3 percent) experience a serious muscle-damaging condition known as rhabdomyolysis. This is defined as necrosis of the muscle fibers that causes weakness, pain, and tenderness. Increasing numbers of individuals are unable to take these commonly prescribed drugs for lowering cholesterol because of this painful muscle problem.  The most accepted theory as to why this occurs seems to be that statin drugs deplete an important enzyme called Co-enzyme Q.  When CoQ levels are low (especially in heart muscle) they can induce sore muscles.  Supplementing with 100 mg or more of CoQ daily seems to solve the problem, unless long-term statin drugs induced rhabdomyolysis. 

Note: Very low plasma total cholesterol (less than 150 mg/dL) has been shown to increase the risk of depression and mortality. These adverse effects are believed to hinder the important role of cholesterol’s delivery of antioxidants throughout the body.

Note: Approximately 30-50% of individuals who have heart attacks do not have a history of heart disease or hyperlipidemia. The problem may be atherosclerosis, i.e., a hardening of the arteries or a chronic inflammatory process of the arterial walls. The evidence that atherosclerosis is an inflammatory disorder is overwhelming. LDL’s are subject to pro-inflammatory modifications that account for their tendency to harden arteries, while HDL’s has an anti-inflammatory property that contributes to their ability to protect the heart against atherosclerosis.

SUPPLEMENT PROTOCOL

  1. DIETARY FIBER
    Dietary fiber, including pectin and psyllium, is a significant part of a low fat diet. Other foods that are particularly potent antioxidant and anti-inflammatory agents include plant pigments such as lycopene (tomato paste), green tea, quercetin, tumeric, anthocyanidins from grapes and berries, and rosemary.
  2. RED YEAST RICE
    Red yeast rice extracts that grow on rice in China have been found to decrease three types of lipids; total cholesterol, LDL, and triglycerides. This supplement is a safe and effective natural yeast that contains a form of statin (similar to prescription drugs like Mevacor). Red rice yeast also contains other potential lipid-lowering agents, such as ten other monacolin analogs (enzymes that inhibit cholesterol biosynthesis), omega-3 fatty acids, isoflavones, and plant sterols (B-sitosterol, sapogenin). While red rice yeast has no real effect on HDL, supplementation with 1,200 mg daily for 8 weeks may lower total cholesterol by 17%, LDL by 22%, and triglycerides by 12%. This herb may be as effective as most statin drugs, at one-seventh the cost. Dosage: 500 mg 2-6 times a day. Caution: There have been reports of muscle myalgias (a necrosis of the muscle fibers that causes weakness, pain, and tenderness) with red rice yeast supplementation. See your health care practitioner if muscle problems occur. Supplement with Coenzyme Q10 if taking red rice yeast.
  3. NIACIN (VITAMIN B3)
    Niacin is the single most effective agent for lowering LDL and triglycerides, while increasing HDL. Niacin has been shown to reduce coronary death and non-fatal myocardial infarction. Flushing, headache, and itching may be side-effects, and high doses of niacin may increase liver toxicity. In combination with INOSITOL HEXANIACINATE, slightly better results are obtained and less flushing occurs. Dosage: 500-1,000 mg up to 3 times a day. High doses (up to 3 grams a day) substantially reduce cholesterol levels and LDL by 20-25 %. It may be beneficial to take niacin with CHROMIUM and other B vitamins.
  4. POLICOSANOL
    An extract from the wax of sugarcane and beeswax, policosanol inhibits cholesterol synthesis at the earliest steps of cholesterol production. It helps the liver normally produce cholesterol and promotes normal LDL cholesterol uptake in the tissues. At doses of 20 mg per day, policosanol has lowered total cholesterol and LDL by more than 20% and raised HDL by 15%. Policosanol has been well studied, appears safe and effective, and lowers several cardiovascular risk factors including liver function, cardiovascular disease, decreased HDL’s, platelet aggregation, and intermittent claudication. Policosanols derived from beeswax and/or rice bran may be inferior to those derived from sugar cane. Dosage: 5-20 mg a day.
  5. PLANT STEROLS
    While cholesterol is the sterol of mammals, phytosterols are the sterols of plant cells. These are the fats of plants. They are found in vegetable oils, corn, and rice. Structurally similar to cholesterol, plant sterols are able to act as a stand-in for cholesterol and block its absorption. Plant sterols are recommended by the American Heart Association as an effective adjunct therapy for reducing low-density lipoprotein and total cholesterol. One study showed an increase benefit of plant sterols combined with endurance training to lower plasma lipids. Over 100 published studies show lipid-lowering effects, especially when combined with soy. Dosage: 1,000- 3,000 mg daily.
  6. GARLIC
    Garlic is the best known of the lipid-lowering herbs. It appears to lower total cholesterol by 5-12% and may reduce triglycerides by 17%. The benefits of long-term garlic consumption may have to do more with cardiovascular benefits (anti-inflammatory action) than simply lowering lipids. German research has shown that adding garlic to the diet reduces cholesterol 4 times more than reducing cholesterol by diet alone. Dosage: 2-4 cloves daily; 2,000-4,000 mcg allicin daily.
  7. GUGULIPIDS
    Guggul is made from the resin of the Indian mukul tree. Taken from a centuries-old Ayurvedic medicine, guggul not only reduces LDL, but has been shown to decrease total serum cholesterol by 11%, drop triglycerides 16%, and increase HDL cholesterol in 3-6 weeks of supplementation. No adverse effects have been reported other than mild diarrhea and nausea. Dosage: 500 mg (standardized to 25 mg gugulsterone) 2-3 times daily. Guggul has been found to help prevent clot formation, and may reduce the effectiveness of the drugs propranolol, warfarin (Coumadin) and diltiazem.
  8. CO-ENZYME Q10
    CoQ10 has a potent antioxidant effect and may decrease lipoproteins in circulation. It is also a necessary supplement to take to counter the side-effect of rhabdomyolsis (a necrosis of the muscle fibers that causes weakness, pain and tenderness) in individuals taking statin drugs or red rice yeast. Dosage: 60-200 mg daily.
  9. PANTETHINE
    Pantothenic acid is a form of vitamin B5 that lowers LDL cholesterol and triglycerides by blocking their production. Studies have shown that pantethine inhibits several enzymes and coenzymes involved in cholesterol synthesis, and HMG-CoA, by 50%. Found naturally in eggs and dairy products, pantethine is completely non-toxic. Dosage: 600-1,200 mg daily.
  10. OMEGA-3 FATTY ACIDS (FISH OIL/FLAX SEED) and KRILL OIL
    Fatty acids found in fish oil (EPA/DHA) and flax seeds (GLA) are especially effective at lowering high triglycerides; however, omega-3 can slightly raise LDL count. Fish oil plus statins may be an effective combination therapy. Combinations of fish oil, flaxseed, and garlic have a beneficial effect on serum lipid concentrations. Dosage: 1-4 grams daily. Recent studies suggest that krill oil may actually improve total cholesterol, triglycerides, HDL and LDL numbers better than fish oil.  At lower or equal doses, krill oil was found more effective than fish oil for the reduction of glucose, triglyceride and LDL levels. Dosage: 2-3 grams daily.
  11. CURCUMIN
    A spice from India also known as tumeric root, curcumin has a positive impact on a number of diseases, including cholesterol reduction. It works by increasing cholesterol excretion in bile and preventing reabsorption in the gut. Curcumin is an anti-inflammatory COX-2 inhibitor that may decrease triglycerides by 11% and increase HDL by 29%. Dosage: 500-1,500 mg daily.
  12. RESVERATROL
    Resveratrol is one of the ingredients in red wine (also contains grape seed extract) and is thought to be part of its healthy effects.  Resveratrol may lower LDL and total cholesterol.  Dosage: See package.
  13. CITRUS PECTIN
    Modified citrus pectin (MCP) is a form of pectin that has been altered so that it can be easily absorbed by the digestive tract. Pectin is a carbohydrate found in most plants and has been shown to lower cholesterol levels. Pectin is particularly plentiful in fruits such as apples, grapefruits, and plums. Dosage: 800 mg 3-6 times a day.
  14. SOY PROTEIN (ISOFLAVONES)
    Recent government research concludes that soy consumption significantly reduces total cholesterol, LDL by 12.9% and triglycerides by 10.5%, but only slightly increases HDL. Soy protein is better than pure isoflavones and works in synergy with phytosterols. CAUTION: Soy may elevate thyroid hormone and should not be taken within 4 hours of thyroid extract intake. Dosage: 25-50 grams protein, 15-75 mg isoflavones.
  15. TOCOTRIENOLS
    Tocotrienols are unsaturated forms of tocopherols derived from rice bran and palm oil. In addition to showing anti-cancer activity, they lower LDL 10-20% by regulating the production of HMG-CoA reductase in the liver. Dosage: 100-400 mg daily.
  16. B-COMPLEX VITAMINS
    By effectively decreasing homocysteine levels, B vitamins have a positive effect on cardiac function. They can also successfully reduce high serum cholesterol. Take extra B6 (pyridoxine), B12, folic acid, and B5 (pantothenic acid), all of which may play a role in the metabolism of fat and cholesterol. Dosage: 50-100 mg daily of B’s. Vitamin B6 may increase to 200 mg daily; folic acid 1,000 mcg daily; vitamin B5 up to 500 mg daily.
  17. L-ARGININE and L-CARNITINE
    Although L-arginine is involved in multiple areas of human physiology and metabolism, its greatest role may be as a precursor of nitric acid. This results in relaxation of vascular muscles and reduced platelet aggregation. Statin drugs have been show to be a problem in individuals with inhibited nitric acid synthesis. L-carnitine has clearly demonstrated reduction of plasma lipoprotein in individuals with high cholesterol, especially in those with type-2 diabetes. Dosage of L-arginine: 350 mg 3-6 times daily. Dosage of L-carnitine: 330 mg 2-6 times a day.
  18. VITAMIN C W/BIOFLAVONOIDS
    Since LDL carries cholesterol into the arterial wall and HDL carries it out, oxidation of HDL interferes with reverse cholesterol transport. Antioxidants like vitamin C protect against oxidation. Therefore high plasma levels of vitamin C help maintain high HDL levels. Dosage: 1000-3000 mg daily.
  19. COCONUT OIL
    Pure coconut oil is one of the healthiest and most versatile unprocessed dietary oils in the world. Extra virgin coconut oil is rich in lauric acid, capric acid, and caprylic acid. These are super fatty acids with strong anti-microbial properties that help maintain healthy HDL and LDL cholesterol ratios. Dosage: see package.
  20. CHROMIUM
    This essential trace mineral can raise the good HDL cholesterol. Chromium deficiency in humans can cause many health problems, including elevated triglycerides and elevated body fat percentage. Dosage: 200 mcg daily.
  21. CINNAMON
    Recent studies are promising, showing that cinnamon may reduce the risk factors associated with diabetes and cardiovascular disease. Results show that participants’ glucose and triglyceride levels were reduced by 18% to 30%, and LDL cholesterol levels dropped by 7% to 27%. Dosage: 4-6 drops of 100% pure cinnamon oil daily, about 1 gram daily.
  22. IP6 (INOSITOL HEXAPHOSPHATE) and PHOSPHATIDYLINOSITOL (PI)
    IP6 supplementation in a recent test resulted in a 19-35 percent decrease in total cholesterol and a significant decrease in triglycerides. Some studies have shown that PI can stimulate reverse cholesterol transport by enhancing the flux of cholesterol into the good HDL. Dosage: IP6 300-1,200 mg daily; PI 2-5 grams daily for at least 2 weeks.
  23. MAGNESIUM
    A magnesium deficiency (very common in the American diet) increases LDL cholesterol buildup in the blood vessel walls. Oral doses of magnesium at 400-600 mg daily improve HDL levels.
  24. NATURAL VITAMIN E
    Fat-soluble vitamins such as vitamin E and BETA CAROTENE reduce LDL cholesterol, the carrier of fat in circulation. Dosage: Vitamin E 200 IU daily. Beta Carotene 5-15,000 IU daily.
  25. PHOSPHATIDYLCHOLINE (PC)
    PC is a primary phospholipid in cell membranes and circulating lipoprotein in the bloodstream. Phosphatidylcholine has the potential to decrease absorption of dietary cholesterol. Dosage: 400 mg 1-3 times a day.
  26. MEDICAL MUSHROOMS
    All Oriental mushrooms (Shiitake, Maitake, Reishi, Cordyceps) appear to have a cholesterol-lowering, anti-viral, and immune-boosting property. Dosage: see a qualified practitioner.
  27. ALFALFA SAPONINS
    Studies monitoring the use of alfalfa saponins have indicated improvement in total cholesterol levels when consumed. Dosage: As directed.
  28. ARTICHOKE
    This leaf contains a phenolic acid called cynarin that is thought to increase cholesterol excretion by inhibiting the liver synthesis of cholesterol, thus blocking gut absorption. In one study artichoke supplementation decreased total cholesterol by 18.5%. Dosage: 250-2,000 mg daily.
  29. GREEN TEA
    Green tea has been shown to lower “bad” cholesterol and serum triglyceride levels. In a recent study reported in a leading medical journal, total cholesterol and LDL levels were significantly lowered by theaflavin-enriched green tea extract when used in combination with low-saturated-fat diets. Dosage: 1-2 cups daily.
  30. CHITOSAN
    Chitosan is a fiber composed of chitin, which is a component of shellfish. It has a magnetic binding affinity for fat and cholesterol, which are excreted in the bowels. Dosage: As directed on package.

GENERAL PROTOCOLS FORMULATED BY DR. BOB ROUNTREE, MD 

For elevated LDL

Inositol hexaniacinate, tocotrienols, curcumin, garlic, soy protein, flax seed or Krill oil, and pantethine.

For high triglycerides 

Krill or Fish oil, garlic, inositol, Fenugreek, psyllium seeds, guggulipid, L-carnitine and pantethine.

For low HDL

A fish oil, calcium citrate, soy protein, niacin, phosphatidylinositol, and green tea.

 

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