Lower Your Cholesterol! Evidence-based strategies!

Read on to learn about powerful lifestyle and medical interventions to manage your cholesterol!!

High cholesterol is a common condition affecting nearly half of all adults in the United States (Karr, 2017). High cholesterol is defined as total cholesterol greater than 200mg/ dL (CDC, 2021). Imbalances of HDL cholesterol and LDL cholesterol raise the risk of cardiovascular disease, heart attack, and stroke.

Cholesterol imbalances can lead to plaque buildup within blood vessels, leading potentially to diminished blood flow to nearly every organ system of the body.

In fact, when cholesterol levels exceed 240 mg/ dL the risk for atherosclerosis (fatty deposits in the arteries) related to cardiovascular disease DOUBLES compared to persons with cholesterol levels in the normal range!! (Karr, 2017).

Cholesterol goals are generally as follows (Uptodate, 2022):

• Total cholesterol lower than 200 mg/ dL
• HDL cholesterol greater than 40 mg/dL and ideally 60mg/ dL or higher
• Triglycerides less than 150 mg/ dL

Lowering your LDL cholesterol is a research-backed strategy to lower the likelihood of you experiencing a stroke or heart attack (Mann, S., Beedie, & Jimenez, 2014). 

Read on to learn powerful lifestyle and medical treatment approaches to lower your cholesterol and risk of cardiovascular disease!

Risk factors

Foods high in saturated fat such as meat, cheese, dairy, cream, and coconut oils contribute to high cholesterol.

Risk factors for high cholesterol include the following:

• Diets high in saturated fat. Saturated fats are predominantly found in meats, cheese, dairy, butter, cream, coconut and palm oils, cakes, cookies, and snack foods (Health.gov, 2020).
• Diets high in trans fats. These are found naturally in milk and meat, and artificially in fried and baked goods (look for hydrogenated or partially-hydrogenated oils in the ingredients list, even if trans fats are listed as zero) (American Heart Association, 2022)
• Lack of physical activity/ lack of exercise
• Smoking
• Overweight/ obesity (find out how losing 5-15% of your body weight improves the health of your various organs and improves cholesterol level in our article “Losing weight: losing a little goes a long way!”
• Kidney disease, diabetes, gallbladder disease, high blood pressure, and hypothyroid disease all can raise LDL cholesterol levels (Karr, 2017). 
• Medications such as diuretics, and glucocorticoid steroids can raise LDL cholesterol levels (Karr, 2022).
• Genetic risk factors can play a role based on various genetic mutations that appear most prevalent in white, non-Mexican Hispanic, and black populations (Karr, 2022).

Strategies to lower your cholesterol 

Non-pharmacologic (non-drug) approaches

Exercise creates a “dose-response,” meaning as exercise increases, total cholesterol, HDL, and triglycerides improve to a greater extent.

The best strategies to lower cholesterol may involve both medication and non-medication approaches. Among the non-medication approaches, current research supports the following:

1. Exercise: research has consistently shown as exercise activity increases, HDL levels increase and LDL cholesterol levels decrease (Mann et al, 2014).
   1.  Exercise exhibits a “dose” response, meaning the more time spent exercising, the more significant the effects.
   2. Research has noted that just 20-30 minutes of aerobic exercise 3 times a week can lead to significant improvements in HDL cholesterol and lowering of total cholesterol.
   3. Light to moderate-intensity resistance training lasting 40-50 minutes 3 times per week significantly improved triglyceride levels, and HDL levels, and lowered total cholesterol and LDL levels.
2. Weight-loss: losing more than 5% of body weight can lead to significant improvements in lipid profiles by raising HDL cholesterol levels and significantly lowering triglycerides (Ryan & Yockey, 2017).
3. Dietary changes as outlined below can lead to significant reductions in LDL cholesterol and triglycerides (Clifton, 2019):
   1. Lower consumption of saturated fat-containing foods (dairy, meat, eggs, creams, butter) to levels lower than 75% of the general population in terms of total amounts consumed.
   2. Increase soluble fiber (found in oats, peas, beans, apples, citrus fruits, carrots, and barley, among other fruits and vegetables) to at least 3 – 7 grams of fiber daily.
   3. High-quality carbohydrates: trade low-quality high-glycemic carbohydrates (sugar, baked goods, refined bread, etc) with carbohydrates from high-quality, low-glycemic sources, such as those found in whole grains, beans/ legumes, non-processed fruits, and vegetables.
   4. Omega 3’s: found in flaxseeds, chia seeds, fish, fish oil supplements, or algae oil supplements–these have been shown to reduce triglycerides
4. Plant sterols and stanols: these compounds interfere with cholesterol absorption. They occur naturally in brown rice, nuts, legumes, vegetables, olive oil, seeds, and seed oils. They can also be supplemented. Up to 2 grams/day can lower cholesterol by 10% (Clifton, 2019)
5. Garlic: a growing body of research consistently notes that garlic in a variety of forms can lower cholesterol modestly by binding to the HMG-CoA reductase enzyme (the same enzyme-bound by statin drugs) that is involved in cholesterol synthesis within the body (Sun, Wang, & Qin, 2018).
   1. Care must be taken when consuming garlic in large quantities or on a regular basis due to blood-thinning properties.
   2. Garlic should be stopped prior to any surgical procedures. Always let your doctor know what supplements you are taking.
6. Nutraceuticals:  a variety of nutraceuticals such as berberine are being researched for their effects on cholesterol and vascular health. The research on some of these is promising though studies showing they reduce cardiovascular events are lacking (Bianconi et al., 2018).

Compounds naturally occurring in plant-based foods can block the absorption of cholesterol as well as prevent its creation in the body!

Red rice yeast extract and current concerns

Red rice yeast extract has demonstrated efficacy in reducing cholesterol levels in a variety of research studies (Dujovne, 2017). Red rice yeast extract has been shown to be of similar effectiveness in lowering cholesterol as the statin drug lovostatin (Dujovne, 2017).

The effectiveness is due to the compound found in red rice yeast called monacolin K. This compound has similar effects and side effects as lovostatin.

The problem with red rice yeast extract is that the compound ranges widely in terms of concentration among red rice batches and thus extracts, meaning that dosing for safety or effectiveness becomes uncertain (Dujovne, 2017).

Red rice yeast also contains potential toxins. Citrinin is a toxic fermentation byproduct found in numerous preparations of red rice yeast extract (Memorial Sloan Kettering Cancer Center, 2022).

The FDA has warned consumers against taking red rice yeast extract due to concerns about variation in extracts and batches, and a lack of assurance concerning safety and efficacy (Dujovne, 2017). Liver injury has occurred for consumers of red rice yeast extract (MSKCC, 2022).

Pharmaceutical approaches

Statins combined with other medications can lower cholesterol by up to 85%, as well as decrease the risk of serious cardiovascular events.

1. Statin medications: these are considered the standard treatment for elevated cholesterol as they have demonstrated clear effectiveness in lowering LDL cholesterol as well as decreasing severe cardiovascular events by 24%. LDL cholesterol levels may drop up to 65% or more on statin medications! Statins bind with an enzyme in the body (HMG-CoA reductase), preventing the synthesis of cholesterol (Karr, 2017).
   1. Side effects include muscle pain, gastrointestinal effects, respiratory infections, and headaches. More serious adverse effects including liver injury, muscle injury, and rhabdomyolysis are possible but rare.
2. Bile acid sequestrants: these help the body clear cholesterol by decreasing bile reabsorption, causing the body to convert larger amounts of cholesterol into bile to replace bile lost due to the medication (Karr, 2017). Bile acid sequestrants lower LDL cholesterol by 15-20%.
   1. Side effects: increased risk of bleeding is possible with prolonged usage due to a decrease in absorption of vitamin K (other fat-soluble vitamins may also be absorbed to a lesser extent). Constipation is also a possible side effect. Bile acid sequestrants can also interfere with the absorption of other medications and must be separated from other medication dosings by 1-4 hours before or 4-6 hours after dosing (Karr, 2017). 
3. Fibric acid derivatives: these bind to a receptor (peroxisome proliferator-activated receptor α (PPARα)), and have been shown to reduce triglycerides by up to 50%, which can increase HDL cholesterol by up to 15%, and lower, LDL cholesterol by up to 25%. These medications are also effective at reducing major coronary events (Karr, 2017).
   1. Side effects: when combined with statin medications, the risk of muscle damage and even rhabdomyolysis (a potentially fatal side effect) increases. Interactions with blood thinner medications are also possible (Karr, 2017).
4. Niacin: studies are finding that niacin is ineffective in reducing serious cardiovascular events. Niacin may raise HDL cholesterol but does not appear to significantly lower LDL cholesterol (Karr, 2017). The American College of Cardiology recommends against niacin due to a lack of benefit and risk of harm (Karr, 2017).
   1. Side effects: flushing is a well-known side effect of niacin. When niacin is paired with statin medications, the risk of adverse events from statins increases.
5. Ezetimibe: this medication blocks the absorption of LDL cholesterol in the intestine. This medication is considered a first-line agent when adding medications to statin therapy. It is generally well tolerated (Karr, 2017).
   1. Side effects:  patients with liver disease who are taking statins should not take ezetimibe.
6. PCSK9 Inhibitors:  for patients who fail statin therapy/ do not tolerate statins, PCSK9 inhibitors provide an alternative therapy. Binding with PCSK9 prevents the protein from degrading LDL receptors, allowing more LDL cholesterol to be removed from the blood (Karr, 2017). These medications can be added to statin therapy to further reduce cholesterol. They are given as injections.
   1. Side effects: itching at injection sites, allergic reactions, and possibly an increase in respiratory infections may occur

Recommended strategies for lowering your cholesterol

A physician, CRNP, or licensed medical provider can evaluate your overall risk for atherosclerotic heart disease.

Your risks such as family history, medical history or current diagnoses, race, gender, and age, among other factors are considered when determining the best approach.

For patients at medium or high risk for heart disease, reductions of elevated LDL cholesterol by 30 to 50 % or more may be recommended.

Generally, depending on your cholesterol levels and risk factors, a combination of lifestyle and medication approaches is prescribed.

How Lancaster Wellness can help

Lancaster Wellness is unique, we prescribe meal plans, fitness plans, and when appropriate, medications–360-degree health in one place!

Lancaster Wellness is a full-service medical clinic. We can evaluate your risk factors for cardiovascular disease, test and monitor your cholesterol levels, and work with you to create a treatment plan that is agreeable to you and supportive of your healthcare goals.

At Lancaster Wellness, we have meal plans that emphasize a “plant-slant” which we can fine-tune to match your caloric needs and weight goals. These meal plans include delicious, research-backed options such as:

• Mediterranean diet meal plans
• Flexitarian diet meal plans
• Vegetarian diet meal plans 
• Vegan diet meal plans 

Our weight loss program can help you shed pounds fast, while simultaneously teaching you healthy nutrition and exercise habits that you can sustain long term.

• Custom fitness programs from an ACE-certified personal trainer 
• FDA approved weight loss medications

By combining medical and lifestyle approaches, Lancaster Wellness can help you achieve new levels of health and wellness!

Reach out today to learn more about how we can help you optimize your health and nutrition!!! Live well!

References

Ahajournals.org. (2019). 2019 ACC/AHA Guideline on the Primary Prevention of Cardiovascular Disease: Executive Summary. Retrieved from https://www.ahajournals.org/doi/pdf/10.1161/CIR.0000000000000677 

American Heart Association. (2022). Trans fat. Retrieved from https://www.heart.org/en/healthy-living/healthy-eating/eat-smart/fats/trans-fat 

Bianconi, V., Mannarino, M. R., Sahebkar, A., Cosentino, T., & Pirro, M. (2018). Cholesterol-Lowering Nutraceuticals Affecting Vascular Function and Cardiovascular Disease Risk. Current cardiology reports, 20(7), 53. https://doi.org/10.1007/s11886-018-0994-7 

Centers for Disease Control and Prevention. (2021). Cholesterol. Retrieved from https://www.cdc.gov/cholesterol/index.htm

Clifton P. M. (2019). Diet, exercise and weight loss and dyslipidaemia. Pathology, 51(2), 222–226. https://doi.org/10.1016/j.pathol.2018.10.013 

Dujovne C. A. (2017). Red Yeast Rice Preparations: Are They Suitable Substitutions for Statins?. The American journal of medicine, 130(10), 1148–1150. https://doi.org/10.1016/j.amjmed.2017.05.013 

Health.gov. (2015-2020). Cut down on saturated fats. Retrieved from https://health.gov/sites/default/files/2019-10/DGA_Cut-Down-On-Saturated-Fats.pdf 

Karr S. (2017). Epidemiology and management of hyperlipidemia. The American journal of managed care, 23(9 Suppl), S139–S148.

Mann, S., Beedie, C., & Jimenez, A. (2014). Differential effects of aerobic exercise, resistance training and combined exercise modalities on cholesterol and the lipid profile: review, synthesis and recommendations. Sports medicine (Auckland, N.Z.), 44(2), 211–221. https://doi.org/10.1007/s40279-013-0110-5 

Memorial Sloan Kettering Cancer Center. (2022). Red rice yeast. Retrieved from https://www.mskcc.org/cancer-care/integrative-medicine/herbs/red-yeast-rice 

Ryan, D. H., & Yockey, S. R. (2017). Weight Loss and Improvement in Comorbidity: Differences at 5%, 10%, 15%, and Over. Current obesity reports, 6(2), 187–194. https://doi.org/10.1007/s13679-017-0262-y 

Sun, Y. E., Wang, W., & Qin, J. (2018). Anti-hyperlipidemia of garlic by reducing the level of total cholesterol and low-density lipoprotein: A meta-analysis. Medicine, 97(18), e0255. https://doi.org/10.1097/MD.0000000000010255

Uptodate.com. (2022). Patient education: High cholesterol and lipids (Beyond the Basics). Retrieved from https://www.ajmc.com/view/epidemiology-and-management-of-hyperlipidemia-article