According to the Center for Disease Control and Prevention, over 33% of American adults have unhealthy cholesterol levels, and 2/3 are not currently treating it (CDC Vital Signs, accessed October 11, 2014). There are no signs or symptoms of high cholesterol. Without regular cholesterol testing, there is no way to detect a problem until there is a consequence. Unfortunately, the most common outcome of unhealthy cholesterol is suffering a heart attack or a stroke. Nearly 25% of people do not survive their first heart attack.
What is cholesterol?
- Cholesterol is a waxy-like lipid (fat) substance present in all cells of the body.
- We use cholesterol for a variety of essential functions such as making sex hormones, adrenal gland hormones, producing vitamin D after sun exposure, and the proper functioning of nerve cells.
Where do we get cholesterol?
- We make cholesterol and we eat foods that contain cholesterol (dietary cholesterol).
- Our bodies synthesize all the cholesterol we need to survive. All dietary cholesterol is “extra.”
- The 2010 Dietary Guidelines for Americans recommends that dietary intake should not exceed 300 mg/day. Most people exceed that and get about 600 mg/day in their diet. UPDATE: The 2015 Dietary Guidelines for Americans Committee proposes eliminating this recommendation. It is important to monitor saturated fat intake.
- Dietary cholesterol comes from animal-derived products.
- Meat, poultry and full-fat dairy are high in dietary cholesterol.
- Organ meats (i.e., liver, brain, kidneys) are very high in dietary cholesterol. So is egg yolk (not egg white).
- Fish and seafood are healthy choices; even though they contain some dietary cholesterol, these foods are generally lower in cholesterol than meat and poultry. Also, fatty fish, like salmon, fatty tuna, and mackerel are rich in omega-3 fatty acids. Omega-3 fatty acids are considered heart-healthy.
- Plants contain no cholesterol.
Nutrient Claims about Cholesterol
For a food to be considered (or labeled) low in cholesterol, it must be low in saturated fat as well as low in cholesterol. There are criteria that must be met for a food to carry a "cholesterol free," "low cholesterol" or "reduced or less cholesterol" food label. It can get confusing because the definitions are not as clean and tidy as consumers would like.
- Cholesterol Free: Per every serving, the product must contain less than 2 mg of cholesterol and less than or equal to 2 g of saturated fat.
- Low Cholesterol: Per serving, products must contain 20 mg or less cholesterol and less than or equal to 2 g of saturated fat.
- Reduced or Less Cholesterol: To carry this label, the food product must contain at least 25% less cholesterol and 2 grams or less saturated fat per serving than the reference food. It is not always clear what the reference food is.
- Fat Free: The claim of "fat-free" means that there is less than 0.5 g of fat per serving.
- Saturated Fat Free: Per serving, a product with this nutrient claim contains less than 0.5 g of fat and the level of trans fat is less than or equal to 0.5 g.
- Low Saturated Fat: This claim means that for each serving of the product, there is less than or equal to 1 g of saturated fat and not more than 15% of the kilocalories come from saturated fatty acids.
As you can see, these label definitions are a bit tedious. The American Heart Association - Q&A about Food Labeling website (accessed 10/13/2014) has a lot more information about this topic and includes some specific information about trans fats and food labels.
What are lipoproteins?
Cholesterol is not water soluble and our bodies are mostly water. Cholesterol has to be transported in a transport vehicle like other large, fat-soluble substances. The vehicles that transport cholesterol along with other fat (lipids in the form of triglycerides), fat soluble vitamins, and some fat soluble plant chemicals are called lipoproteins. Lipoproteins are compounds made up of a protein rich, water compatible outer shell and a lipid rich inner core.
There are four types of lipoproteins: chylomicrons, very low density lipoproteins (VLDL), low density lipoproteins (LDL), and high density lipoproteins (HDL).
Why is high LDL a problem?
Wardlaw GM and Smith AM (2013) Lipids. Contemporary Nutrition, 9th Edition (pp. 166-201). New York, NY: McGraw Hill.
Blausen.com staff. "Blausen gallery 2014". Wikiversity Journal of Medicine. DOI:10.15347/wjm/2014.010. ISSN 20018762.
Cholesterol & Triglyceride Values (Lipid Chemistries)
*Risk factors
These risk factors significantly increase a person's risk for heart disease. If you have any of these risk factors, it is possible that your healthcare practitioner will decide to take a very active approach to managing what might seem like moderate abnormalities of your cholesterol levels (low HDL and high LDL).
The following are other risk factors that may place you in a higher risk category.
Mayo Clinic - What do your cholesterol numbers mean (accessed 10/12/2014)
University of Maryland (accessed 10/12/2014)
Food Choices for the Cholesterol-Conscious
The 2010 Dietary Guidelines for Americans recommend that dietary cholesterol intake not exceed 300 mg/day. You can look at food labels to determine how much cholesterol is in prepackaged foods either by looking at the mg per serving or at the percent daily value (% DV). Look for items that contain less than or equal to 5% cholesterol per serving. That is considered a low-cholesterol amount per serving. Foods that provide 20% DV cholesterol per serving are considered high cholesterol foods. Those are foods to limit or eat with awareness if you are concerned about cholesterol intake.
A diet that is low in saturated fat will be low in cholesterol. A heart-healthy diet includes lean proteins, vegetable proteins, a variety of fresh fruits, vegetables, whole grains, and fiber. Many people find that soluble fiber, the type of fiber present in oats, is particularly effective at lowering LDL-cholesterol level.
Soluble Fiber
Nuts and Peanuts
In the typical American diet, we get omega-6 fatty acids from corn oil, safflower oil, cottonseed oil, and soybean oil. We more than meet our dietary needs every day. Eating fish, nuts, legumes and using vegetable oil in place of saturated fat is a healthy way to increase the amount of omega-6 fatty acids you consume. At this time, it is not recommended that people take omega-6 supplements unless they have been advised to by their physician.
Several research studies support the American Heart Association’s recommendation and some offer reasons to explain why PUFAs may reduce the risk of heart disease (2-7). Linoleic acid has specifically been shown to reduce LDL cholesterol at the cellular level. Evidence indicates that one way that linoleic acid works is by increasing the production of LDL receptors and then promoting the receptors to localize on the surface of cells. These LDL receptors are needed to pick up LDL from the blood. This helps lower the amount of LDL-cholesterol circulating in the blood and in that way reduces the chance of cholesterol from LDL being deposited in the arteries. There is also evidence that linoleic acid increases the production of bile acid, which contains cholesterol and is needed for fat digestion, as well as the breakdown of cholesterol (8, 9).
Omega-3 PUFA: Alpha-Linolenic Acid
Omega-3 fatty acids, like alpha-linolenic acid, are also PUFAs. In the typical American diet, we tend to under-consume foods that contain omega-3 fatty acids (9). Foods rich in omega-3 fatty acids include fatty fish like salmon, albacore tuna, catfish, halibut and mackerel, and plant foods like flaxseed and walnuts. Omega-3 fatty acids are considered heart healthy but exert their effects in different ways than the omega-6 fatty acids. Increasing omega-3 rich foods in the diet is a heart-healthy choice and is strongly recommended. Some research indicates that people who eat foods rich in omega-3 fatty acids have a lower risk of experiencing a heart attack or stroke (10,11).
It is believed that omega-3 fatty acids reduce the risk for cardiovascular disease through a variety of non-cholesterol related ways. They may help decrease the formation of arterial plaques, promote blood flow through blood vessels and arteries, and reduce the risk of forming clots that may lead to a heart attack or stroke. Increasing the presence of omega-3 rich foods in your diet and decreasing foods rich in saturated fats is a heart-healthy choice that is believed to contribute positively to your overall health primarily through preventing and reducing inflammation. By themselves, omega-3 fatty acids will not directly change your lipid profile.
ATTENTION people with coronary heart disease: It is not recommended that people with pre-existing coronary heart disease take supplements of any type of PUFA (linoleic acid or alpha-linolenic acid) without first discussing it with their primary care physician. If you have been diagnosed with heart disease, talk to your physician about any supplement you consider taking.
American Heart Association Recommendations
Will diet and exercise fix my cholesterol?
What are lipoproteins?
Cholesterol is not water soluble and our bodies are mostly water. Cholesterol has to be transported in a transport vehicle like other large, fat-soluble substances. The vehicles that transport cholesterol along with other fat (lipids in the form of triglycerides), fat soluble vitamins, and some fat soluble plant chemicals are called lipoproteins. Lipoproteins are compounds made up of a protein rich, water compatible outer shell and a lipid rich inner core.
There are four types of lipoproteins: chylomicrons, very low density lipoproteins (VLDL), low density lipoproteins (LDL), and high density lipoproteins (HDL).
Why is high LDL a problem?
- Cholesterol-rich LDL circulates in the bloodstream, delivering cholesterol to cells. Cells have LDL receptors on them to receive cholesterol.
- When cells don't need any more cholesterol, they quit putting out receptors for it and stop picking up any more cholesterol. This leaves LDL "stranded" out in circulation with cholesterol.
- LDL's job is to deliver cholesterol and if its usual targets are not receiving it, then it starts to deposit the cholesterol elsewhere. Elsewhere means extra cholesterol gets deposited in the blood vessels and arteries.
- Plaques form.
- Plaques are cholesterol-rich substances that form in blood vessels.
 |
| "Blausen Gallery 2014." Lipid deposits of plaque. Plaque contain lots of cholesterol. |
- It is now becoming clearer that plaques start to develop during childhood, which is decades earlier than was previously thought. This has many implications, one being that we need to start preventing later heart disease very in early in life and another being that heart disease can manifest earlier in life than expected.
- As plaques accumulate, they impair the flow of blood through the vessel.
- A heart attack occurs when blood flow to the heart is obstructed.
- A stroke occurs when blood flow to brain is obstructed.
Wardlaw GM and Smith AM (2013) Lipids. Contemporary Nutrition, 9th Edition (pp. 166-201). New York, NY: McGraw Hill.
Blausen.com staff. "Blausen gallery 2014". Wikiversity Journal of Medicine. DOI:10.15347/wjm/2014.010. ISSN 20018762.
Cholesterol & Triglyceride Values (Lipid Chemistries)
- Total cholesterol (HDL+LDL+20% of triglycerides)
- Optimal: 180 mg/dL
- Desired: < 200 mg/dL
- Borderline High: 200-239 mg/dL
- High: >/= 240 mg/dL
- HDL-cholesterol (good)
- Higher is better
- Men
- < 40 mg/dL poor
- 40-49 better
- >/= 60 best
- Women
- < 50 mg/dL poor
- 50-59 mg/dL better
- >/= 60 best
- LDL-cholesterol (bad)
- < 70 mg/dL ideal, particularly for those at high risk for heart disease*
- < 100 mg/dL desirable, this is the target for most people - those not identified specifically as being at high risk for heart disease
- 100-129 mg/dL near ideal
- 130-159 mg/dL borderline high
- 160-189 mg/dL high
- > 190 mg/dL very high
- Triglycerides
- 150 mg/dL desirable
- 150-199 borderline high
- 200-499 high
- >/= 500 very high
*Risk factors
These risk factors significantly increase a person's risk for heart disease. If you have any of these risk factors, it is possible that your healthcare practitioner will decide to take a very active approach to managing what might seem like moderate abnormalities of your cholesterol levels (low HDL and high LDL).
- Previous heart attack
- Having a history of arterial blockages in your neck, arms, and/or legs
- Diabetes (type 1 or type 2)
The following are other risk factors that may place you in a higher risk category.
- Smoking (smoking itself damages blood vessels)
- High blood pressure (the increased force required to pump blood damages the arteries and may increase the risk of forming a clot, dislodging plaque, and obstructing blood flow)
- Men over the age of 45, women over the age of 55
- Family history of heart disease (there are genetic components that influence cholesterol uptake and metabolism)
Mayo Clinic - What do your cholesterol numbers mean (accessed 10/12/2014)
University of Maryland (accessed 10/12/2014)
Food Choices for the Cholesterol-Conscious
The 2010 Dietary Guidelines for Americans recommend that dietary cholesterol intake not exceed 300 mg/day. You can look at food labels to determine how much cholesterol is in prepackaged foods either by looking at the mg per serving or at the percent daily value (% DV). Look for items that contain less than or equal to 5% cholesterol per serving. That is considered a low-cholesterol amount per serving. Foods that provide 20% DV cholesterol per serving are considered high cholesterol foods. Those are foods to limit or eat with awareness if you are concerned about cholesterol intake.
A diet that is low in saturated fat will be low in cholesterol. A heart-healthy diet includes lean proteins, vegetable proteins, a variety of fresh fruits, vegetables, whole grains, and fiber. Many people find that soluble fiber, the type of fiber present in oats, is particularly effective at lowering LDL-cholesterol level.
Soluble Fiber
- Soluble fiber reduces how much cholesterol is absorbed from the diet. It binds up cholesterol and prevents it from being absorbed into the bloodstream.
- Some people find that incorporating soluble fiber into their cholesterol management program helps reduce blood cholesterol.
- In order for soluble fiber to work, a person needs to consume at least 5-10 g of soluble fiber every day to have any impact on the LDL-cholesterol level.
- For reference, 1 1/2 cup of cooked oatmeal = 6 g soluble fiber
- Can increase that to about 10 grams by adding fruit
- Soluble fiber will not have any effect unless 5-10 grams/day are consumed every day
- Other soluble fiber foods:
- Apples
- Kidney beans
- Pears
- Barley
- Prunes
Nuts and Peanuts
Walnuts, almonds, hazlenuts, peanuts, pecans, pistachios are rich in polyunsaturated fatty acids (PUFAs), good sources of protein, low in saturated fat, and have no cholesterol. They may have a positive effect on the health of blood vessels and may help to lower LDL-cholesterol. Nuts are high calorie food items though, so it is important to remember that. Nuts can be a satisfying, flavorful, and nutritious way to add diversity to your diet. All that is needed and recommended is a handful of nuts per day (which is about 1.5 oz or 42.5 g). Experts suggest that nuts replace something in the diet.
Lean Protein
- Vegetable proteins like soybeans, quinoa, beans, and lentils
- Soybeans and quinoa are excellent sources of protein
- Pair other plant proteins with rice, corn, or nuts
- Lean meat
- Chicken without skin and with fat removed
- Fish
- Turkey without skin and with fat removed
- Egg yolk contains cholesterol but egg whites do not. If you are monitoring your cholesterol intake and are a regular egg eater, you might consider limiting egg yolks to 3-4 days a week. Eggs are low in saturated fat. Even though they contain cholesterol, they are a good source of protein and many other nutrients.
- Lean cooking methods
- Select vegetable oils like olive oil and canola oil
- Cook with broth instead of oil
- Grill, broil, bake
- Sautee, steam, grill, or microwave vegetables
- Use bold spices and reduce salt (often a little salt goes a long way when used with bold spices)
Omega-6 PUFA: Linoleic Acid
In 2009, the American Heart Association recommended that at least 5-10% of a person’s total caloric intake come from omega-6 polyunsaturated fatty acids (PUFAs) such as linoleic acid (1). Replacing saturated fatty acids with PUFAs is the most successful and beneficial approach to improving lipid profiles. In the typical American diet, we get omega-6 fatty acids from corn oil, safflower oil, cottonseed oil, and soybean oil. We more than meet our dietary needs every day. Eating fish, nuts, legumes and using vegetable oil in place of saturated fat is a healthy way to increase the amount of omega-6 fatty acids you consume. At this time, it is not recommended that people take omega-6 supplements unless they have been advised to by their physician.
Several research studies support the American Heart Association’s recommendation and some offer reasons to explain why PUFAs may reduce the risk of heart disease (2-7). Linoleic acid has specifically been shown to reduce LDL cholesterol at the cellular level. Evidence indicates that one way that linoleic acid works is by increasing the production of LDL receptors and then promoting the receptors to localize on the surface of cells. These LDL receptors are needed to pick up LDL from the blood. This helps lower the amount of LDL-cholesterol circulating in the blood and in that way reduces the chance of cholesterol from LDL being deposited in the arteries. There is also evidence that linoleic acid increases the production of bile acid, which contains cholesterol and is needed for fat digestion, as well as the breakdown of cholesterol (8, 9).
Omega-3 PUFA: Alpha-Linolenic Acid
Omega-3 fatty acids, like alpha-linolenic acid, are also PUFAs. In the typical American diet, we tend to under-consume foods that contain omega-3 fatty acids (9). Foods rich in omega-3 fatty acids include fatty fish like salmon, albacore tuna, catfish, halibut and mackerel, and plant foods like flaxseed and walnuts. Omega-3 fatty acids are considered heart healthy but exert their effects in different ways than the omega-6 fatty acids. Increasing omega-3 rich foods in the diet is a heart-healthy choice and is strongly recommended. Some research indicates that people who eat foods rich in omega-3 fatty acids have a lower risk of experiencing a heart attack or stroke (10,11).
It is believed that omega-3 fatty acids reduce the risk for cardiovascular disease through a variety of non-cholesterol related ways. They may help decrease the formation of arterial plaques, promote blood flow through blood vessels and arteries, and reduce the risk of forming clots that may lead to a heart attack or stroke. Increasing the presence of omega-3 rich foods in your diet and decreasing foods rich in saturated fats is a heart-healthy choice that is believed to contribute positively to your overall health primarily through preventing and reducing inflammation. By themselves, omega-3 fatty acids will not directly change your lipid profile.
ATTENTION people with coronary heart disease: It is not recommended that people with pre-existing coronary heart disease take supplements of any type of PUFA (linoleic acid or alpha-linolenic acid) without first discussing it with their primary care physician. If you have been diagnosed with heart disease, talk to your physician about any supplement you consider taking.
American Heart Association Recommendations
- Nutrition Center
- Newsroom (accessed 10/13/2014):
“The American Heart Association continues to recommend limiting saturated fats to less than seven percent of total calories consumed and supports eating between five to ten percent of total calories from Omega-6 PUFAs, within the context of an overall healthy dietary pattern that emphasizes fruit, vegetables, high-fiber whole grains, low-fat dairy products, lean meat, poultry and fish,” Kris-Etherton said.http://newsroom.heart.org/news/no-change-in-aha-recommendations-on-saturated-or-poly-unsaturated-fat
References
1. Harris WS, Mozaffarian D, Rimm E, et al. Omega-6 Fatty Acids and Risk for Cardiovascular Disease: A Science Advisory From the American Heart Association Nutrition Subcommittee of the Council on Nutrition, Physical Activity, and Metabolism; Council on Cardiovascular Nursing; and Council on Epidemiology and Prevention. Circulation. 2009;119(6):902-7.
2. Kris-Etherton P, Fleming J, Harris WS. The debate about n-6 polyunsaturated fatty acid recommendations for cardiovascular health. J Am Diet Assoc. 2010;110(2):201-204.
3. Jakobsen MU, O'Reilly EJ, Heitmann BL, et al. Major types of dietary fat and risk of coronary heart disease: a pooled analysis of 11 cohort studies. Am J Clin Nutr. 2009;89(5):1425-1432.
4. Mozaffarian D, Micha R, Wallace S. Effects on coronary heart disease of increasing polyunsaturated fat in place of saturated fat: a systematic review and meta-analysis of randomized controlled trials. PLoS Med. 2010;7(3):e1000252.
5. Sacks FM, Katan M. Randomized clinical trials on the effects of dietary fat and carbohydrate on plasma lipoproteins and cardiovascular disease. Am J Med. 2002;113 Suppl 9B:13S-24S.
6. Kris-Etherton PM, Hecker KD, Binkoski AE. Polyunsaturated fatty acids and cardiovascular health. Nutr Rev. 2004;62(11):414-426. (PubMed)
7. Mensink RP, Katan MB. Effect of dietary fatty acids on serum lipids and lipoproteins. A meta-analysis of 27 trials. Arterioscler Thromb. 1992;12(8):911-919.
8. Fernandez ML, West KL. Mechanisms by which dietary fatty acids modulate plasma lipids. J Nutr. 2005;135(9):2075-2078.
9. Jones PJH and Rideout T (2014) Lipids, sterols, and their metabolites. In AC Ross, B Caballero, RJ Cousins, et al (Eds.) Modern Nutrition in Health and Disease, 11th Edition (pp. 65-87). Baltimore, MD: Lippincott Williams & Wilkins.
10. Mozaffarian D, Wu JH. Omega-3 fatty acids and cardiovascular disease: effects on risk factors, molecular pathways, and clinical events. J Am Coll Cardiol. 2011;58(20):2047-2067.
10. Mozaffarian D, Wu JH. Omega-3 fatty acids and cardiovascular disease: effects on risk factors, molecular pathways, and clinical events. J Am Coll Cardiol. 2011;58(20):2047-2067.
11. Hooper L, Thompson RL, Harrison RA, et al. Risks and benefits of omega 3 fats for mortality, cardiovascular disease, and cancer: systematic review. BMJ. 2006;332(7544):752-760.
Linus Pauling Institute (Accessed 10/13/2014)
Body
Weight and Physical Activity
Maintaining a healthy body weight or losing
small amounts of weight, if you are overweight or obese, can have a significant
effect on overall health. For some, losing 5-10 pounds can improve cholesterol by contributing to lower LDL-cholesterol and higher HDL-cholesterol. Additionally, weight loss can improve blood pressure. With overweight and obesity, a general guideline is that a 5-7% reduction in
body weight is usually adequate to see an improvement in blood lipid profiles and blood pressure. Weight loss should be gradual. Gradual weight loss means 0.5 to 1 lbs per week. A maximum weight loss that is considered safe and effective is 2 lbs per week. Anything more than that is likely to be transient and should be monitored by a medical team. Weight loss is most effective when combined with regular exercise.
It is recommended that adult Americans get at least 30 minutes of moderate exercise at least 5 days a week. This comes out to 150 minutes of moderate exercise weekly. Figuring out how to schedule this into already busy days is often the most challenging part of making the task of exercise a pleasure or an enjoyable habit. It does help with cholesterol, blood pressure, stress management, energy levels, and sleep quality. Regular
exercise combined with a diet that is rich in fresh fruits, vegetables, whole
grains, and low in saturated fat has a
positive effect on lipid profiles, blood pressure, insulin sensitivity, and
reduces the overall risk of cardiovascular disease.
For anyone not currently engaged in a regular exercise program, it is recommended that you consult with a physician before starting something new (especially if you are over the age of 40). For many people, it only takes 150 minutes of moderate exercise a week combined with a healthful diet to have an impact on cholesterol (lower LDL cholesterol, increase HDL-cholesterol, and lower triglycerides. This is 30 minutes of moderate activity 5 days a week. For some people, more than 30 minutes per day is needed to lose weight or maintain weight loss.
For anyone not currently engaged in a regular exercise program, it is recommended that you consult with a physician before starting something new (especially if you are over the age of 40). For many people, it only takes 150 minutes of moderate exercise a week combined with a healthful diet to have an impact on cholesterol (lower LDL cholesterol, increase HDL-cholesterol, and lower triglycerides. This is 30 minutes of moderate activity 5 days a week. For some people, more than 30 minutes per day is needed to lose weight or maintain weight loss.
Will diet and exercise fix my cholesterol?
For some people, diet and exercise will normalize their cholesterol levels; it will reduce their LDL and raise their HDL cholesterol. Some people will require a combination of diet, exercise, and medication. I am unaware of any official public health recommendation that states that medication alone without any dietary and exercise changes on the part of the individual will be used to treat cholesterol. There are genetic factors and some genetic diseases that result in abnormal cholesterol levels. When this is the case, medication is going to be needed. Also, when underlying medical conditions are present like diabetes or arterial diseases that impact blood flow, medication will likely be needed to reduce the risk of serious cardiovascular complications. But even when medication is prescribed, reducing saturated fat and cholesterol in the diet and increasing exercise per the physician's recommendations are important components of the health plan. Like high blood pressure, high cholesterol is a silent condition. Prevention is the best measure. Empowering ourselves with information to make informed decisions about our health is our best armor.
If your doctor sends you off without a good explanation of what your labs mean, call the office back and ask for more information, a referral to a certified health coach, or a registered dietitian.
If your doctor sends you off without a good explanation of what your labs mean, call the office back and ask for more information, a referral to a certified health coach, or a registered dietitian.
Some useful websites
Mayo Clinic
Cleveland Clinic
Center for Disease Control and Prevention
University of Arizona
About Cholesterol and Lipids
* Updated 3/9/2015
University of Arizona
About Cholesterol and Lipids
* Updated 3/9/2015
