Do you know your cholesterol numbers? They are too high for more than half of all American adults. The culprit is LDL cholesterol—low-density lipoproteins, the bad kind—in their blood. Manufactured by the liver, cholesterol is a critical building block of cell walls, hormones, and digestive juices. But overly high LDLs are a major cardiovascular risk. Along with liquified fat, dead cells, and other cellular trash, they can form deposits within the walls of the coronary arteries; as these deposits, or plaques, grow, they may bulge into the artery, interfering with blood flow. If one ruptures and a clot forms, a heart attack or stroke is likely. If you haven't had your cholesterol checked with a quick blood test, now would be a good time. Adults are advised to get their levels tested at least once every five years.
Reducing the risk from high LDLs can be accomplished in either of two ways: by lowering the amount of LDLs produced by the body, or by increasing the rate at which LDLs are sent back to the liver to be destroyed. Statins and other drugs can reduce LDL production by as much as 70 percent. Dietary changes usually produce less-dramatic effects but are important, especially cutting back on foods high in saturated fats, which promote LDL formation. Limiting high-cholesterol foods like egg yolks and liver helps, but isn't likely to make a big dent. Speeding up the rate of getting LDLs out of circulation relies on pushing up the level of HDLs—high-density lipoproteins, the good cholesterol—because shuttling LDLs back to the liver is their main job. But raising good cholesterol is much harder than lowering the bad variety. Want details on reducing your LDLs and bumping up your HDLs? Keep reading.
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Joseph Keenan, a cardiology researcher and professor emeritus at the University of Minnesota, has a love-hate relationship with statins. On the one hand, he prescribes them to many patients. On the other, he can't use them to control his own dangerously high cholesterol. Like many of the 25 percent or so of patients prescribed statins who abandon them within six months, Keenan has had unpleasant side effects, such as muscle spasms, and blood tests indicate muscle damage. "It came as a shock," he says of finding out he'd have to do without his Lipitor.
What recourse do people like Keenan have? Some doctors, such as Steven Nissen of the Cleveland Clinic, are so convinced of statins' lifesaving power that they first require patients to try all six before considering them intolerant. Next, patients might try a nonstatin drug such as Zetia, which lowers cholesterol by inhibiting its absorption in the intestine. But there are other weapons besides drugs in the cholesterol wars. For those intolerant of statins—and for people taking them as well—the following strategies can help defeat unhealthy cholesterol.
Diet. The foundation of any cholesterol-lowering regimen is a balanced diet. That doesn't mean you have to buy only products whose labels scream "low cholesterol." In fact, says Christopher Gardner, a researcher at Stanford University who specializes in nutrition, a varied diet that emphasizes plants, fish, legumes, whole grains, and fruits is significantly better at lowering problematic cholesterol than a more conventional diet of prepared foods equally low in saturated fats and cholesterol. Why? Components of plant-based diets actively interact to improve cholesterol profiles, he suggests. That said, you'll still want to limit your intake of red meat, eggs, and cheese.
The so-called Mediterranean diet, the dash (Dietary Approaches to Stop Hypertension) diet, and the Ornish Diet (which is particularly low in meat and dairy) are variations on this approach. One study found that a balanced diet did just as well as a statin at reducing bad cholesterol. Dean Ornish, the founder of the Preventive Medicine Research Institute in Sausalito, Calif., has shown that his multipronged approach (diet, exercise, stress reduction, and social support), while not easy to maintain, can lower LDL by nearly 40 percent and even cause plaques in arteries to shrink—which not even statins have been proven to do.
Exercise. Regular exercise is also critical. Some studies show that regular aerobic exercise for a period of about 12 weeks can modestly increase beneficial HDL cholesterol—between 5 and 10 percent, and more for some people. Your triglyceride level and blood pressure should respond, too. Shoot for at least 30 minutes of moderate aerobic exercise five to seven days a week.
Supplements. Natural food stores and the Internet are awash with products claiming to improve cholesterol profiles. For most, there is little or no evidence of an effect on cholesterol levels (though some—Omega-3 fatty acids, for example—have not been studied rigorously enough to say definitely that they don't work).
Notable exceptions worth exploring include niacin, plant sterols, and soluble fiber supplements. Though niacin can raise blood sugar and cause flushing, a daily dose can raise HDL levels by 15 to 35 percent and lower LDL levels by about 20 percent. Niacin has a risk of side effects, however, especially when combined with a statin. A daily serving of plant sterols (about 2 grams), in fortified foods such as margarine, orange juice, and rice milk, can also lower LDL by about 15 percent. Eating plenty of soluble fiber, which occurs naturally in products such as oats, nuts, flax, and psyllium husk and in dietary supplements such as Metamucil, can also drop LDL. Red rice yeast, a popular dietary supplement, also works. But be warned that it contains lovastatin, the active ingredient in Mevacor, a prescription statin, and is "essentially an unregulated statin," says Robert Vogel, a cardiologist at the University of Maryland.
Lifestyle interventions often don't work nearly as well as a statin can. Exercise, a better diet, and supplements can generally reduce bad cholesterol by 20 to 40 percent, compared with 60 to 70 percent for statins. But Keenan estimates that 70 percent of people with problematic cholesterol levels could gain control with lifestyle changes alone. He has. His LDL levels are down by about 60 percent thanks to diet, exercise, niacin and other supplements. That's as good a job, he says, as Lipitor did.
By Adam Voiland, 2/6/2008
Your doctor tells you that your level of LDL—the "bad" type of cholesterol—is too high, and, in a double whammy, he says that your level of HDL—the "good" cholesterol—is too low. So, you wonder, is there anything you can do to decrease the bad while increasing the good?
There are steps you can take to accomplish this. It's much easier to push LDL down than to push HDL up, but it's well worth the effort to strive to do both. A November study published in the Postgraduate Medical Journal found that increasing HDL levels in patients who are also aggressively lowering their LDL levels can reduce cardiovascular risk. An HDL level of 60 milligrams per deciliter or higher is believed to help protect against heart disease. Women's risk for heart disease rises significantly at HDL levels below 47 mg/dL; men are at particular risk if their HDL level falls below 37 mg/dL.
For LDL, a reading of 190 mg/dL or higher is considered to be very high, 160 to 189 is considered to be high, and 130 to 159 is considered to be borderline high. A level of 100 to 129 is considered to be near optimal; less than 100 is considered optimal for most people. But for those who are at very high risk for heart disease or have a history of heart trouble, a reading of less than 70 is preferred.
Depending on your cholesterol levels, successfully reaching your target levels will probably take a combination of medication and lifestyle and dietary changes. Among the changes you'll have to make: Stop smoking, work out, lose weight, and eat well, the PMJ study suggests.
If you're up to the task, here are 10 ways to lower your LDL and raise your HDL:
1. Taking a statin can lower LDL by 10 percent (at the lowest dose) to 55 percent (at the highest dose), says Robert H. Eckel, professor of medicine at the University of Colorado-Denver and past president of the American Heart Association. A small percentage of people who take statins experience severe myopathy, which is muscle discomfort or weakness. Statins also bump up HDL, typically by 5 to 10 percent (that's only 2 to 4 mg/dL, not enough to make much of a difference). Other types of cholesterol-lowering medications are sometimes prescribed in combination with statins.
2. A cholesterol absorption inhibitor would be a likely next step for those who can't take statins because of side effects, Eckel says. There is only one such drug—ezetimibe (Zetia). A 2003 study in the journal Pharmacotherapy found that when given alone or in combination with other cholesterol-lowering medications, ezetimibe reduced LDL by 15 to 20 percent and raised HDL, but, as with a statin, not by much—2.5 to 5 percent.
3. Bile acid sequestrants can decrease LDL by about 10 to 20 percent, according to the National Heart, Lung, and Blood Institute. When combined with a statin, these medications can lower LDL by more than 40 percent. Medications in this class—cholestyramine, colestipol, and colesevelam—come in pill or powder form. The powder must be mixed with water or juice before being taken. These drugs offer an added benefit for diabetics: Recent research has shown they help to lower blood glucose levels.
4. Nicotinic acid, also known as niacin, is a water-soluble B vitamin that lowers LDL by 10 to 20 percent and is the only drug that can have a real impact on HDL, says Eckel. According to the NHLBI, it can lift HDL levels by 15 to 35 percent. A study published this month in Current Medical Research and Opinion says that niacin and fibrates (explained below) are underutilized—either alone or in combination with statins—to treat low HDL and high triglycerides (a kind of fat in the blood). Because most people who take niacin experience flushing of the skin and a warm feeling, particularly on the face, neck, and ears, up to half of those taking the medication choose to stop it, according to the Mayo Clinic.
5. Fibrates are mostly effective at lowering triglycerides and in heightening HDL levels, according to NHLBI. These drugs usually lower LDL by 10 to 20 percent, Eckel says. For those who take this type of medication, HDL increases are usually in the neighborhood of a modest 10 to 15 percent.
6. Lose weight. This can lower LDL, though levels will go back up unless you make lasting dietary changes, Eckel says. Aim to lose 10 percent or more of your body weight. Keep in mind that while you're losing weight, your HDL levels may fall, Eckel warns. But as you maintain your new body weight, your HDL will increase as long as you've lost at least 10 percent of your body weight. Try U.S. News's 10-week workout routine to help you get started, and avoid these 7 mistaken beliefs that can prevent weight loss.
Exercise itself can raise HDL, although usually not by a meaningful amount. "For sedentary people with low HDL cholesterol and heart disease, even a little bit of exercise can raise it—but not by a lot," Eckel says. "For the average Susan or Joe, moderate aerobic activity needs to be accompanied by a change in body composition—less fat—to increase HDL." There are a few caveats: Women who have abnormal menstrual periods have minimal increases in HDL, and too much resistance training may actually lower HDL cholesterol if not accompanied by some aerobic training.
7. Limit saturated fats. Eating saturated fats—which are the main diet-linked cause of high cholesterol—tends to raise your HDL, but it also increases your LDL. These fats are mostly found in animal foods such as beef, lamb, poultry, pork, butter, cream, and milk, and in coconut and coconut oil, palm and palm kernel oil, and cocoa butter. "We think the bad cholesterol is more of a concern than the good cholesterol," says Eckel, so it's important to limit consumption of saturated fats. The American Heart Association recommends limiting saturated fat intake to less than 7 percent of your total daily calories. "A reduction in saturated fats by a moderate amount will reduce LDL," Eckel says.
8. Avoid trans fats, which have been purged from many prepared foods but are found in small quantities in some animal products. They also are formed during the hydrogenation process of making margarine, shortening, and cooking oils. Trans fats can increase LDL and decrease HDL. Vegetable oils that are partially hydrogenated are the source of about 75 percent of trans fatty acids in the American diet, according to the AHA. It's easier now to find foods that contain little to no trans fats, as more attention is paid to how trans fats affect people's health. Many restaurants are making an effort, and New York City and California have banned trans fats.
As a rule, try to limit your intake of trans fats to less than 1 percent of your total calories on any given day, the AHA suggests. Read the nutrition facts label when you buy food to keep an eye on how much trans fat you're consuming. "Look at the ingredients, and if ingredients say hydrogenated or partially hydrogenated, there are trans fats in there," says Barry Franklin, director of cardiac rehabilitation at the William Beaumont Hospital in Royal Oak, Mich.
9. Have an occasional drink. Drinking alcohol increases HDL levels slightly but doesn't decrease LDL, according to NHLBI. Because drinking too much alcohol can result in alcoholism, damage to the liver and the heart muscles, high blood pressure, and high triglyceride levels, among other problems, it's important to limit consumption. Men and women who consume alcohol should do so in moderation, which means one to two drinks daily for men and one drink for women, the AHA suggests.
10. Quit smoking. There are plenty of reasons to stop, but one that's not widely known is that smoking has been shown to decrease HDL levels. Smoking also makes it harder to work out, which means it is less likely you'll reach healthful cholesterol goals. And that's not all. Consider these other reasons why you should stop smoking right now.
By January W. Payne, 5/27/2009
More Articles on Cholesterol:
- Does My Kid Really Need a Cholesterol Test?
- Statins for Prevention? Taking a Cholesterol-Lowering Drug When Cholesterol Is Normal
- 2 Ways to Lower Your Child's Cholesterol Without Statins
- The Skinny on Fats: What the Latest Research Says About What You Should Be Eating
- The Cardiologist's Perspective on Cholesterol
- The Smart Take on Statins