The Good, the Bad and the Ugly
Since the advent of effective medications for lowering cholesterol - and direct-to-consumer advertising on the behalf of pharmaceutical companies - many people now have some understanding of cholesterol and its importance in heart health.
But how well do you understand the importance of your cholesterol? For most people, cholesterol is something they work really hard to get down - at least they work really hard the week or so before their doctors visit when they know it will be checked!
Many people know there is a “good” cholesterol and a “bad” cholesterol- but do you know there is also an “ugly” cholesterol?
And why, when the week or so before the appointment wasn’t enough to get your cholesterol values in range, is your doctor so insistent on you taking a statin (some of your doctors may want you to take a statin regardless ofyour cholesterol numbers)?
Finally, are there alternatives to taking statin medications that are as effective?
I hope this articles helps you better understand the importance of all the numbers and will provide you with some quick tips on how to lower the “bad”, raise the “good” and minimize the “ugly”.
The “Good” Cholesterol: HDL
Think of the “H” as “Heart Healthy” or “High” because for HDL, the higher the numbers are, the better your heart health. Current recommendations for people with diabetes advise an HDL greater than 40 mg/dL.
So how do you raise it?
HDL cholesterol is increased by several healthful behaviors- the most important of which is exercise! Exercise, especially cardiovascular exercise (i.e. exercise that raises your heart rate to 65% of your maximum effort or higher), is the number one factor that influences HDL cholesterol levels and is a critical element of a healthy lifestyle and long-term avoidance of complications of diabetes.
Interestingly alcohol also raises HDL cholesterol, however alcohol has risks associated with it too- including raising blood pressure. So how much alcohol is healthy and how much is too much? I do not recommend anyone use alcohol as an alternative to exercise in an effort to raise HDL cholesterol - the benefits are not the same. However, the clinical research on alcohol is clear - one drink per day for women and two drinks per day for men appears to modestly increase lifespan. It is important to remember that an alcoholic “drink” many not be your “drink” at home (i.e. technically an alcoholic drink is 4 oz. of wine, a 12 oz. beer, or 1oz. of spirits).
Other therapies that raise HDL cholesterol include omega-3 fatty acids, especially fish oil.
The “Bad” Cholesterol: LDL
Think of “L” as “Lousy” or “Low” because for LDL, the lower the number the better for your heart health. Current recommendations for people with diabetes advise an LDL lower than 100 mg/dL (some guidelines now recommend lower than 70 mg/dL). Elevated LDL cholesterol is a serious risk factor for the development of heart disease and therefore a serious risk factor for having a heart attack or stroke.
LDL cholesterol becomes elevated in response to the food we eat including dietary cholesterol and saturated fat. Statin medications are particularly effective at lowering LDL cholesterol and have demonstrated impressive reductions in cardiovascular events (i.e. heart attack, stroke and death) in clinical trials.
In particular, the Heart Protection Study demonstrated a 25% reduction in cardiovascular events within the five years of the study in people with diabetes by lowering LDL cholesterol by 30% using a statin (Heart Protection Study Collaborative Group, Lancet, 2002). Interestingly these findings were not related to the level of LDL before it was lowered! Because of these findings, statin medications have become “standard of care” for adults with diabetes- which is why your doctor probably recommends them frequently!
The “Ugly” Cholesterol: Small, dense, oxidized LDL
As with most aspects of human health, the situation gets more complicated when you start looking more deeply at cholesterol. Although most physicians talk to you about your total LDL level this is not the whole story. As referenced in a recent review on stroke prevention by cardiologist David Spence, your non-fasting oxidized LDL (oxLDL) may be more significant (Spence, Stroke, 2006 and Diaz et al. N Engl J Med, 1997).
LDL cholesterol is particularly susceptible to oxidation or rust. Some of this oxidation occurs during the cooking process while the remainder appears to occur within the body; in clinical research investigating oxLDL, researchers often use food like burgers from fast food restaurants, pizza, and egg breakfast sandwiches to induce the oxidation they are researching!
OxLDL cholesterol is particularly sticky, adheres to walls of our blood vessels, stimulates inflammatory processes, and leads to rapid atherosclerosis.
Laboratory testing can give you information on your LDL subfractions - including your small, dense LDL cholesterol. I use LDL subfractions to help determine how aggressively I need to treat LDL cholesterol. For example, if a patient has a LDL cholesterol of 110 (just over the recommended 100) but has very little small, dense LDL I may chose to treat with minor dietary modifications. If a patient has an LDL cholesterol of 110 and the majority of the cholesterol is small, dense cholesterol, I will treat more aggressively with diet and may consider prescription therapies to further lower their LDL.
Are there Alternatives to Statins?
The best alternative to statin medication is preventing the need by getting daily exercise (increases HDL) and following a well-balance, low saturated fat diet rich in plant-based protein, legumes (beans), whole grains, and fruits and vegetables with the elimination of trans fats.
The Mediterranean Diet has demonstrated greater cardiovascular protection than statin medications in some clinical trials (deLorgeril et al., Circulation, 1999 and Scandinavian Simvistatin Survival Study Group, Lancet, 1994). One theory for the benefits of the Mediterranean Diet is the density of plant pigments and other antioxidants in the recommended foods - see Stop the Rust!
Another dietary alternative for LDL reduction, though less studied, is the Portfolio Diet - a relatively simple low saturated fat diet that includes generous soy protein, fiber, almonds, and plant sterols (Jenkins et al., Am. J. Clin. Nutr., 2006).
What about Supplements?
There are many supplements which report cholesterol lowering effects all with varying degrees of credibility to back these reports.
Supplemental omega-3 oils, especially fish oils, are clearly protective to the cardiovascular system. Studies demonstrate the regular intake of fish oil and/or regular intake of cold-water fish (not fried or breaded!) improves life span and is associated with a 36% reduction in cardiovascular related death (Mozaffarion et al. JAMA, 2006). Fish oils also lower triglycerides and improve HDL levels.
Supplemental plant sterols are also effective for lowering total and LDL cholesterol and appear to be effective at lowering cholesterol in people with genetically elevated cholesterol as well as “statin non-responders” (Moruisi et al., J Am. Col. Nutr., 2006). However the clinical research on plant sterols has not given us any information on whether supplementation reduces events or increases lifespan.
Other supplements commonly used to treat elevated cholesterol include garlic, niacin, Red Yeast Rice and policosanol.
Clinical trial data on supplemental garlic is conflicting and I do not recommend garlic consumption for solely this purpose at this time. Garlic is full of important antioxidants and may have additional health benefits including cancer prevention, however I think it is best to consume garlic as food while following the Mediterranean Diet.
Niacin is a B-vitamin and has been long been used to lower LDL cholesterol and raise HDL cholesterol. The doses needed to impact cholesterol are much greater than those needed for daily vitamin needs. Niacin is available as a prescription in sustained-release formulations with seem to be better tolerated than quick release niacin. Side effects from niacin are common and include flushing and liver inflammation; although common these side effects can be minimized through dose titration and dose timing. Niacin remains an inexpensive and effective treatment for elevated LDL cholesterol and reduced HDL cholesterol.
Red Yeast Rice is the origin of statin medications and has been used in Asia for centuries as a food additive (Red Yeast Rice give the reddish color to Peking Duck!). Red Yeast Rice contains many constituents that are similar is structure and function to statin medications and it does lower LDL cholesterol. (Of note, both statin medications and Red Yeast Rice lower coenzyme Q10 levels - an important cofactor in metabolism and heart health - however this lowering may or may not be important to low term health.)
For people who do not feel good about taking a pharmaceutical medication, but who really need to lower their cholesterol, Red Yeast Rice is an effective choice. My experience has been that Red Yeast Rice is tolerated better than statin medications, but it is not tolerated well by everyone! Also, it is important for you to know, although statin medications are derived from Red Yeast Rice, we cannot superimpose all research findings for statins over those for Red Yeast Rice. We still do not have a study documenting reduced cardiovascular events by using Red Yeast Rice.
Policosanol was once a promising alternative to statin medications. Early studies performed in Cuba suggested dramatic LDL lowering action. These studies were criticized for being small and had not been replicated outside of Cuba. Subsequent studies, including a large, well-designed clinical trial published this year, conflicted with earlier studies and suggested policosanol is ineffective for LDL reduction (Berthold et al, JAMA, 2006). My clinical experience is similar - I do not use policosanol clinically because I cannot rely on the results with my patients.
Interestingly, some nutritional supplement companies who manufacture and sell policosanol suggest the study findings would have been different is “our” policosanol had been used; “ours is nano-encapsulated and super-absorbed.” I don’t know about you, but in my opinion little separates a super-processed, nano-encapsulated product from a synthetic pharmaceutical. In fact, because the data is better for the pharmaceutical than for the supplement, in this situation I would recommend taking the pharmaceutical!
Where to Put your Time, Money and Energy
In my opinion, the following tips will improve your heart health, increase your “Healthy HDL”, lower your “Lousy LDL”, and dramatically reduce your “Ugly oxLDL”.
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Exercise regularly and daily is better: Raises HDL and lowers LDL
Follow a Mediterranean Diet eating style: Lowers LDL and oxLDL
Consume alcohol in strict moderation (one drink per day for women, two per day for men): Raises HDL
Consider adding the Portfolio Diet for additional LDL reduction
Limit egg yolk consumption and eat omega-3 enriched eggs if possible (i.e. one egg yolk per day on average): Lowers oxLDL
Eat red meat in strict moderation (i.e. once a month): Lowers LDL and oxLDL>
Avoid trans fats: Lowers LDL and oxLDL
Consider a daily dose of blueberries or pomegranate: Lowers oxLDL
Eat cold-water fish or supplement omega-3 oils regularly (200-250 mg of EPA/DHA per day, or 1500-2000 per week): Raises HDL
If your LDL is still > 100 after changing your diet, I recommend using a statin medication, supplemental plant-sterols, Red Yeast Rice, or niacin to lower your LDL. At times combinations of these agents can be used but these should be discussed with your physicians to ensure proper monitoring.
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