Article: Lower cholesterol naturally with a combination of foods, Part 1
When I was in school for my master's degree in nursing to become a family nurse practitioner (FNP), I grappled with how to explain risk to people in a way that we all could understand. While everything has inherent risks (even making dietary changes), we all have varying degrees of risk tolerance. My experience in the clinic has taught me that most of us see dietary changes and medications for lowering cholesterol as "either or" options, but the solution for some can be "both". Below, I'm going to explain the original research behind food interventions to lower cholesterol with the knowledge that for some of us, statin therapy may not be enough. No matter what our goals are, achieving and maintaining a lower Apo B concentration and inflammatory markers (like C-RP) does lead to a lower risk of heart attack and stroke over the lifetime. Here's a place to start.
In 2002 researchers asked the question, how effective do cholesterol lowering foods compare to low-dose statins (cholesterol lowering medications)(1)? Using a standard dose of 3 different foods based on daily calorie needs, Jenkins and colleagues found that they could lower participants cholesterol in their blood as well as low-dose statin therapy (lovastatin 20 mg once daily), reaching maximal benefit in as little as two weeks (1). They report a 29% lowering of LDL cholesterol in a study of 345 participants (1). As Apolipoprotein B (ApoB for short) is a molecular marker of LDL particle number in the blood, they saw this improve as well (1).
Okay, but what did they eat? plant sterols (1 g/1,000 kcal), soy protein (23 g/1,000 kcal), and viscous fibers (9 g/1,000 kcal). There have been 6 additional controlled trials since 2002, all reaching the same conclusion, and the Portfolio diet has evolved (2).
Here is what it looks like as real food:
The 4 core food components of the Portfolio dietary pattern include (based on a 2000 kcal diet): 42 g nuts (tree nuts or peanuts); 50 g plant protein from soy products or dietary pulses such as beans, peas, chickpeas, and lentils; 20 g viscous soluble fibre from oats, barley, psyllium, eggplant, okra, apples, oranges, or berries; and 2 g plant sterols initially provided in a plant sterol-enriched margarine. (2)
In 2010 they realized that adding monounsaturated fat (using sunflower oil or avocado) to the diet could further improve cardiovascular risk markers such as C-Reaction Protein (CRP: a marker of systemic inflammation) (3). They reported an average lowering of CRP by 74.6% but this varied among participants (3).
How much dietary monounsaturated fat did they use? Around 26% of total calories (well within the acceptable macronutrient range). To put this into context, 26% of calories for someone consuming 2,000 kcal/day equates to 520 kcal of added non-tropical plant oil or avocado. The equivalent of roughly 2 fist sized avocados or a little over 4 tablespoons of olive oil. Nuts and seeds are also an option, with a little under 1 cup of raw almonds or cashews reaching this target.
Okay, but what does 2 grams of plant sterols look like? That's the thing! They had people follow a vegetarian diet, low in saturated fat and high in fiber with a maximum of 2 eggs per week (3). "Plant sterols are found in plants like vegetables, fruits, wheat germ, whole grains, beans, sunflower seeds, and many vegetable oils" (4). It was the combination of a vegetarian diet with these "portfolio" additions that made all of the difference. The more whole plant foods that we add to the diet, the higher our intake of plant sterols.
Now, whenever we look at a study, we want to make sure that the people enrolled are similar to us. The average participant was 54 to 65 years old (both genders), overweight (BMI between 25-30) and their average LDL cholesterol at the start of the trial ranged from 162 to 178 (1). A 29% reduction would equate to roughly a 47 and 52 point drop, respectively. That is huge!
The average American LDL cholesterol is around 130 mg/dl, with the average American having a 1 in 3 risk of having a heart attack or stroke in their lifetime (5). In an infamous article written by the then editor-in-chief of the American Journal of Cardiology, with a title so pointed as, "It's the Cholesterol Stupid", Roberts argued that we should be aiming for a level of LDL cholesterol in the blood low enough to actually prevent heart disease and stroke (6). How low? Roberts recommended an LDL cholesterol below 60 (6). As you can imagine, there was an uproar! Obtaining an LDL cholesterol below 60 would mean that we'd all have to go plant-based or start a statin. Let that sink in.
As I will continue to state, any transition towards a dietary pattern with more whole plant foods will improve our health and risk of heart attack and stroke. While some of us may need to lower our cholesterol further in addition to taking a statin, others may simply be able to transition towards a plant predominant dietary pattern to reach goal levels. It all depends on our medical history and our baseline risk. This is not an all of nothing deal, any step in the right direction can further reduce our risk. And yes, some of us might be able to achieve ideal cholesterol levels without medication if the diet is sufficiently plant-based. As in most of medicine, it depends on our specific situation.
Are there other ways to improve our ApoB, LDL cholesterol and markers of systemic inflammation (like C-RP)? Yes. More on that tomorrow. Don't forget to subscribe to the blog so you don't miss out!
If you or someone you know is struggling to improve their risk of cardiovascular disease (heart attack and stroke), Jessica Krol, FNP, DipACLm of Lifestyle Medicine Maine offers intensive therapeutic lifestyle interventions in a practical manner to Maine State residents. If you're ready to make a change, call us today or schedule a FREE new patient intake. Hurry, limited spots are left as our clinician's panel size will initially be capped to ensure that Lifestyle Medicine Maine Members receive adequate support in the Weight Loss and Wellness Group Program. We're excited that your here and we're overwhelmed by your support and readiness to transform your health. Learn more about the Weight Loss and Wellness Program options here.
References
Nutrition calculations in this article were made using data from NutritionValue.com
A dietary portfolio approach to cholesterol reduction: Combined effects of plant sterols, vegetable proteins, and viscous fibers in hypercholesterolemia. Jenkins et al. Journal Metabolism (2002) https://www.sciencedirect.com/science/article/abs/pii/S002604950200166X
Portfolio Dietary Pattern and Cardiovascular Disease: A Systematic Review and Meta-analysis of Controlled Trials. Chiavaroli et al. Journal of Progress in Cardiovascular Disease. (2018) https://www.sciencedirect.com/science/article/pii/S003306201830094X
Adding monounsaturated fatty acids to a dietary portfolio of cholesterol-lowering foods in hypercholesterolemia. Jenkins et al. Canadian Medical Association Journal. (2010) https://www.cmaj.ca/content/cmaj/182/18/1961.full.pdf
Plant Sterols in Foods — Sterol Supplements. Advice from the National Lipid Association Clinician’s Lifestyle Modification Toolbox. The National Lipid Association. (n.d.) https://www.lipid.org/sites/default/files/plant_sterols_in_food_final_0.pdf
Heart Attacks and Cholesterol: Purely a Question of Diet. Dr. Michael Gregor. Nutrition Facts (2011). https://nutritionfacts.org/video/heart-attacks-and-cholesterol-purely-a-question-of-diet/
It's the Cholesterol Stupid. Roberts. American Journal of Cardiology. (2010). 10.1016/j.amjcard.2010.09.022
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