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Cholesterol and food

(article, Catherine Bennett Dunster)

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p(blue). Editor's note: Catherine Bennett Dunster wrote the Health+Food column from June 2007 to April 2008.

"I've been told I have high blood cholesterol. Should I change my diet to lower it?"

It’s definitely worth a try, especially if you’re trying to avoid using cholesterol-lowering medications. According to many heart-disease experts, including the American Heart Association, high cholesterol is considered a primary risk factor for heart disease and stroke. Additional risk factors include smoking, physical inactivity, high blood pressure, obesity, and diabetes. 

Your health-care provider will evaluate your cholesterol panel (a group of tests ordered together and often referred to as a lipid panel) along with other risk factors to determine your overall risk for heart disease. From there, your doctor will recommend options for treatment, which generally include diet and lifestyle therapy, pharmaceutical therapy (cholesterol-lowering medications), or both.

[%image reference-image width=400 float=left caption="Studies have shown that eating two handfuls of almonds a day should lower your LDL cholesterol level."] 

h3. A cholesterol primer 

Low-density lipoprotein (LDL) is considered the “bad” cholesterol, because when too much of it circulates in the blood, it can build up in arteries, possibly forming plaques (along with other substances) that may narrow the arteries. In short, it's not good for optimal blood flow.

High-density lipoprotein (HDL) is referred to as the “good” cholesterol, because it's  believed to carry cholesterol away from arteries and back to the liver (where it is then removed from the body). High levels of HDL are thus thought to protect against heart disease.  

Triglycerides (TG) is a blood fat produced by the body; it's the most common blood fat. It can be elevated due to excess weight, inactivity, excessive alcohol intake, smoking, and a diet very high in carbohydrates (in excess of 60 percent of total calories).  

Astute readers probably already know that cholesterol is vital for several bodily functions: producing hormones, vitamin D, and bile acids. The liver produces amounts necessary for those functions, but due to genetic makeup, sometimes more is produced than needed, resulting in high and potentially dangerous levels of cholesterol. In addition to what the liver produces, we also get cholesterol by consuming foods of animal origin — eggs, meats, seafood, and dairy — as well as foods made from these products. 

h3. Calculating cholesterol levels

Your personal cholesterol goals relate to your other risk factors. The sidebar below shows general number ranges.

h1.Reference ranges from the American Heart Association


Calculating cholesterol ranges isn’t simple, though “ratio” is a word commonly heard at the doctor’s office. Your cholesterol ratio can be helpful in determining heart-disease risk, but not in determining the appropriate treatment to lower that risk; then your health-care provider will want to know absolute numbers. 

|!Total cholesterol||
|Less than 200 mg/dL|Desirable|
|200 to 239 mg/dL|Borderline high|
|240 mg/dL and up|High|
|!HDL cholesterol||
|Less than 40 mg/dL (men)|Low|
|Less than 50 mg/dL (women)|Low|
|60 mg/dL and up|High (protective against heart disease)|
|!LDL cholesterol||
|Less than 100 mg/dL|Optimal|
|100 to 129 mg/dL|Near or above optimal|
|130 to 159 mg/dL|Borderline high|
|160 to 189 mg/dL|High|
|190 mg/dL and up|Very high|
|Less than 150 mg/dL|Normal|
|150 to 199 mg/dL|Borderline high|
|200 to 499 mg/dL|High|
|500 mg/dL and up|Very high|
|!Cholesterol ratio (total cholesterol divided by HDL)||
|Below 5.0 to 1|General goal|
|3.5 to 1|Optimal level|


Miles Hassell, the medical director of the Providence Integrative Medicine Clinic in Portland, Oregon, says that the first question a person should ask after learning of elevated cholesterol levels is, “What's my overall risk for heart disease?” 

Total cholesterol alone, Hassell says, is "a weak predictor" of risk. A 90-year-old healthy guy with elevated total cholesterol but excellent HDL, for example, has a very low risk of developing heart disease. "But if you're a 40-year-old male with high LDL and low HDL, who smokes, has a big gut, and is inactive, then you have a number of risk factors and could probably benefit by improving your numbers,” he says.

h1.American Heart Association recommendations


# Achieve and maintain a healthy body weight by balancing physical activity and calorie intake.
# Eat high-fiber, whole-grain foods.
# Eat a diet rich in fruits and vegetables.
# Eat fish at least twice a week, especially fatty fish.
# Keep saturated fats to 7 percent or less of total calories.
# Keep trans fats to less than 1 percent of total calories by avoiding foods containing “hydrogenated” or “partially hydrogenated” on their ingredient lists.
# Limit cholesterol intake to less than 300 milligrams per day. (One large egg yolk contains approximately 215 mg. cholesterol.) 
# Eat and drink fewer foods and beverages with added sugar.
# Choose (and prepare) foods with little or no salt.
# Drink alcohol in moderation.


Hassell’s approach to treat without pharmaceuticals differs from that of many other practitioners, who follow the standard recommendations set forth by the National Cholesterol Education Program, also encouraged by the American Heart Association. (See sidebar for specifics.) 

“We treat the whole patient, working toward a more fundamentally healthy person,” says Hassell.

h3.Theory in practice

At the Integrative Medicine Clinic, Hassell says, the first priority for a patient with low HDL, high LDL, and high triglycerides is to lower the triglycerides count and increase HDL levels. To do this, practitioners make recommendations for a daily exercise program (for “waist loss”). They also suggest ways to dramatically reduce refined carbohydrates (such as white-flour-based foods and those laden with simple sugars) and to lower alcohol consumption to a moderate level (no more than two drinks per day for men and one per day for women).
“At the same time, we increase the patient’s intake of healthy fats, like extra-virgin olive oil, nuts, and avocadoes, and increase minimally processed fiber, like whole grains and legumes,” says Hassell.

Next, Hassell works on lowering the patient’s LDL levels by following a modified Portfolio diet — a near-vegan regimen using a “portfolio” of foods, each of which has cholesterol-lowering benefits. Patients follow his clinic's version of the portfolio diet along with the established exercise program and dietary changes mentioned above.  

Hassell calls his portfolio diet "modified" because his clinic doesn't focus on reducing saturated fats: fatty meats, whole-milk products, butter, and coconut and palm-kernel oils. (This approach makes it an easy sell for many patients.) The clinic also embraces eggs, because eggs are not only an excellent source of protein containing important nutrients, they're also very low in saturated fats.  

Rather, the clinic recommends eating — every day — four tablespoons of oat bran, two handfuls of almonds, psyllium fiber (such as Metamucil), and extra-virgin olive oil in place of other fats, plus either 200 grams (about two cups, cooked) eggplant or 100 grams (about 10 cooked pods) okra every other day.  

You may be wondering how to go about eating that much okra and eggplant. You might also be  asking, “Does this diet actually work?”
Yes, it does, according to Hassell (and a small but compelling study in the Journal of the American Medical Association). Hassell says that eating the almonds alone should lower LDL levels by 9 or 10 percent; he cautions, though, that “it has to be a daily regimen, just as a regular medication would be.”  


h1.Featured recipes 


Essentially, Hassell’s clinic is encouraging daily exercise with a calorie-appropriate diet that ultimately increases soluble fiber, whole grains, vegetable proteins, and healthy fats while reducing refined carbohydrates and moderating alcohol intake. If followed as recommended, that leaves very little room for foods rich in saturated fats, which many experts blame for raising cholesterol levels. Consequently, the clinic's program falls right in line with the backbone of the AHA’s and NCEP’s cholesterol-lowering models — albeit from a different angle.

What I like about Hassell’s approach is that it’s straightforward, stretching beyond a “foods to avoid” list, taking into consideration the entire patient. In truth, it accomplishes much of what the AHA recommends, but it feels more manageable, enabling patients to more readily adopt it as a lifestyle change.  

On the flipside, the dietary restrictions we’ve had to work with for years — with varying results, depending on compliance and genetics — seem designed to push patients toward non-compliance, which ultimately means one thing: The pharmaceutical companies win when patients decide that cholesterol-lowering medications are easier to swallow than modifying their diet and exercising.

p(bio). Catherine Bennett Dunster is a registered dietitian and a former instructor at Oregon Health and Science University. She lives with her husband and two children in Portland, Oregon. Send questions for the Health+Food column to health+food at

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