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how can Diet have as big an impact on cholesterol as drugs?

Cardiovascular disease (CVD) is currently the leading cause of death worldwide, causing one‐third of deaths globally (1). Yet CVDs are largely preventable by managing modifiable risk factors (2), an overview can be found here.

We need cost-effective strategies to prevent risk factors before they become an issue. For people just generally keen to be optimally healthy, the most effective way to maintain great cholesterol levels and avoiding an increased risk of a heart attack is diet. Specific foods that lower cholesterol, combined with making plants the centre of our diet can lower our LDL cholesterol by 30% in 4 weeks (4). An effect similar to drugs (4). 

 

A poor diet and high blood pressure lead to the most deaths due to CVD (3) but other areas such as raised cholesterol levels also play a significant role (1). Raised LDL cholesterol causes CVD (5) and one-third of all CVD cases around the world are due to high LDL levels (6). 

 

This is down to its role in the narrowing of the arteries in a process called atherosclerosis(7, 8), which is the main cause for CVDs (9, 10). 
 

Considering CVD is killing one in three of us worldwide and costs the NHS a whopping £9 billion a year (31), isn’t time we took control of our health and aim to prevent this lifestyle-driven disease before it takes hold?

 

In this article, we hope to arm you with the info of exactly how to do that considering cholesterol.

 

Cholesterol itself isn’t bad, our liver makes it and it’s used to create hormones like vitamin D as well as helping with the structure of our cell membranes. The low density lipoprotein (LDL) mentioned above is simply the transport for it, taking it to where it’s needed in the body.

 

It acts a bit like the London tube, just transporting cholesterol (instead of people) to where they need to go along routes they would otherwise be unable to travel. Much like a broken down tube train, an LDL transport can be damaged, this occurs through oxidation which is when they become part of the process called atherosclerosis.

 

This narrowing of the artery walls is the key underlying reason for CVD events like heart attacks and strokes (11).

When my Dad passed away, several of the blood vessels leading to his heart had so much of this narrowing, this atherosclerosis from damaged LDL, that there was only a pinhole left open. He died at age 54 (read more on this story here).



 

This narrowing doesn’t happen overnight, it takes a lifetime of suboptimal habits to build up this blockage. It makes sense then, that if there is more LDL transporting cholesterol around our bloodstream there is a greater chance more will be damaged or oxidised, leading to faster atherosclerosis.

Always ask your doctor what your levels should be but the NHS suggests these guidelines: 

LDL to be 3mmol/L or below and total cholesterol to be 5mmol/L or below (12).

We haven’t mentioned HDL here which historically has been known as the ‘good cholesterol.’ Unlike the name suggests, it has no causal link to heart health improvement and recent drug trials which raise it have been stopped due to more people having a CVD event with the artificially higher HDL (13). The complete opposite of what they hoped for. Also, individuals with high HDL from birth also seem to have no protection from CVD so HDL's impact may simply be neutral (14) and is simply an association. 

As previously mentioned, raised LDL levels cause atherosclerosis which is the narrowing of our arteries, high levels of it can even double our CVD risk (15). Research indicates the lower the level, the better (16). So what diets that people are currently following provide the greatest reduction in risk? 1. Vegetarian, 2. Pescatarian and 3. Omnivore (17). So the more that plants are the centre of a diet the lower the LDL levels. 

 

So why is plant-based better than fish or meat-eaters? We've covered in detail why a plant-based diet is generally beneficial for heart health here but for cholesterol, it may be down to the increased fibre of plant foods, which lowers LDL (18).

 

This limits the amount of cholesterol absorbed and also the amount of cholesterol produced in the liver (19). The higher the fibre the better (20). But it’s not too late for anyone, as when omnivores are placed on plant centred diets their LDL cholesterol is reduced by around 0.34–0.36 mmol/L which provides a 9.0 to 10.6% decreased CVD risk (21).

 

The relationship between LDL and CVD risk is dose-dependent, meaning that any increase in LDL, directly raises CVD risk. For every 1% reduction in LDL, the risk for a major CVD event (heart attacks and strokes) is also reduced by 1% (22). 

 

Many Dietetic organisations across the world have endorsed a well planned plant-based diet being beneficial for disease prevention and health promotion (23-30). So if an eating pattern focusing on whole plant foods is the optimal standard diet for LDL health, are there any areas within this regimen we can optimise? 

 
Image by Brooke Lark

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foods that help

As can be seen in the diagram above, there's a clear difference between animal products and plant products and their impact on our cholesterol health. The cornerstone of lowering LDL is starting with a whole-food, plant-centric diet. The best-researched foods that can help optimise this diet are soy products (35), almonds (36), plant stanols and soluble fibre. 

This is known as the portfolio diet (32) which helps lower LDL cholesterol, plant stanols are found in good amounts in sesame seeds, sunflower seeds and pistachios (33), but can also be found in fortified drinks/spreads.

Oats are a fantastic source of soluble fibre, along with barley, eggplant, beans and apples (37). All of which can lower cholesterol (34), with only positive side effects including things like feeling fuller for longer (49).

 

Other foods that may help include, blueberries (38), amla (Indian gooseberry (39)) and legumes (lentils, chickpeas, split peas and beans (40).


Foods that harm

 

There are three parts to what we eat that directly raise LDL levels, these are trans fat, saturated fat and dietary cholesterol. The Institute Of Medicine (IOM) have not set any limits for how much of these we should eat as any consumption over 0g increases risk of death and disease (39). 

Trans fat is found in processed foods (partially hydrogenated) and in cows and sheep (40), regardless of its source it raises LDL cholesterol (40). Many public health programmes are reducing trans fat in processed foods, but this is not feasible with milk and meat products. Cutting out the meat-based trans fat alone has the capacity to lower cardiovascular disease risk by up to 6% (41). 

Saturated fat is found in mostly in animal products including cheese, beef,  tropical oils (palm and coconut), and processed meats (42). Just removing saturated fat isn't enough (43), it must be replaced with health-promoting foods such as polyunsaturated fats or whole grains. In other words, nuts, seeds, soy and lentils rather than doughnuts and sweets. When this is done, LDL cholesterol is lowered and overall CVD risk is more favourable (44). 

Dietary cholesterol, found in organ meats, eggs and many other animal products, can raise cholesterol levels (45, 46). If individuals are already consuming very high amounts of cholesterol then raising their dietary cholesterol further has no impact on LDL levels (45). Regardless, replacing these food sources with foods that help may have a double win for our heart health. 

Other areas that can harm our LDL levels include; unfiltered coffee (47) and alternate-day fasting (48).

Image by am JD

In summary, CVD is the biggest killer of mums, grandpas, friends and colleagues on the planet. Higher HDL is only associated with lower CVD risk whereas raised LDL levels cause atherosclerosis (the narrowing of our arteries), high levels of it can double our CVD risk (15). For every 1% reduction in LDL, the risk for a major CVD event (heart attacks and strokes) is also reduced by 1% (22). 

Generally, plant foods lower LDL while animal foods raise it. According to research, it seems combing a whole foods, plant-based diet with specific foods that optimise our levels, we can lower our LDL by 30% (4), similar to that of drugs (4). 

By making plants the centre of what we eat we can:

- look after our NHS

- lower our chances of CVDs

- reduce our LDL levels

- minimise the impact on our planet (50)

We all have the power to take control of our health to some extent and potentially prevent this lifestyle-driven disease before it takes hold.

In no way is this information meant to replace the advice given by your doctor, always follow the advice of your health professional. Always discuss any lifestyle changes with your doctor.

As always, don't just take our word for it, have a read through some of the evidence we use which is all referenced below. 

Evidence
  1. Benjamin, E.J., Blaha, M.J., Chiuve, S.E., Cushman, M., Das, S.R., Deo, R., De Ferranti, S.D., Floyd, J., Fornage, M., Gillespie, C. and Isasi, C.R., 2017. Heart disease and stroke statistics—2017 update.

  2. Institute of Medicine (US) Committee on Preventing the Global Epidemic of Cardiovascular Disease: Meeting the Challenges in Developing countries 2010.

  3. Wilkins, E., Wilson, L., Wickramasinghe, K., Bhatnagar, P., Leal, J., Luengo-Fernandez, R., Burns, R., Rayner, M. and Townsend, N., 2017. European cardiovascular disease statistics 2017.

  4. Howard BV, Roman MJ, Devereux RB, et al. Effect of lower targets for blood pressure and LDL cholesterol on atherosclerosis in diabetes: the SANDS randomized trial. JAMA 2008;299(14):1678–89. 62. Ornish D, Brown SE, Scherwitz LW, et al. Can lifestyle changes reverse coronary heart disease? The Lifestyle Heart Trial. Lancet 1990;336(8708):129–33.

  5. Ference, B.A.; Ginsberg, H.N.; Graham, I.; Ray, K.K.; Packard, C.J.; Bruckert, E.; Hegele, R.A.; Krauss, R.M.; Raal, F.J.; Schunkert, H.; et al. Low density lipoproteins cause atherosclerotic cardiovascular disease. 1. Evidence from genetic, epidemiologic, and clinical studies. A consensus statement from the European Atherosclerosis Society Consensus Panel. Eur. Heart J. 2017, 38, 2459–2472.

  6. [WHO | Mean cholesterol [Internet]. WHO. [cited 2018 Mar 13];Avail]

  7. Nordestgaard BG. Triglyceride-rich lipoproteins and atherosclerotic cardiovascular disease: new insights from epidemiology, genetics, and biology.Circ Res. 2016; 118:547–563. doi: 10.1161/CIRCRESAHA.115.306249

  8. Ross R, Harker L. Hyperlipidemia and atherosclerosis.Science. 1976; 193:1094–1100.

  9. Gallino A, Aboyans V, Diehm C, et al.; European Society of Cardiology Working Group on Peripheral Circulation. Non-coronary atherosclerosis.Eur Heart J. 2014; 35:1112–1119. doi: 10.1093/eurheartj/ehu071

  10. Ross R. Atherosclerosis–an inflammatory disease.N Engl J Med. 1999; 340:115–126. doi: 10.1056/NEJM199901143400207

  11. Jacobson TA, Ito MK, Maki KC, Orringer C, Bays HE, Jones PH, McKenney JM, Grundy SM, Gill EA, Wild RA et al. . National Lipid Association recommendations for patient-centered management of dyslipidemia: part 1. J Clin Lipidol. 2015a;9(2 Suppl):S129–69.

  12. https://www.nhs.uk/conditions/high-cholesterol/cholesterol-levels/

  13. Honey K. (2007). Drug designed to raise HDL levels falls down. The Journal of clinical investigation, 117(2), 282. https://doi.org/10.1172/JCI31253

  14. Voight, B.F., Peloso, G.M., Orho-Melander, M., Frikke-Schmidt, R., Barbalic, M., Jensen, M.K., Hindy, G., Hólm, H., Ding, E.L., Johnson, T. and Schunkert, H., 2012. Plasma HDL cholesterol and risk of myocardial infarction: a mendelian randomisation study. The Lancet, 380(9841), pp.572-580.

  15. Roger VL, Go AS, Lloyd-Jones DM, et al. Heart disease and stroke statistics—2012 update: a report from the American Heart Association. Circulation. 2012;125(1):e2–e220. doi: 10.1161/CIR.0b013e31823ac046

  16. J H O’Keefe Jr, L Cordain, W H Harris, R M Moe, R Vogel. Optimal low-density lipoprotein is 50 to 70 mg/dl: lower is better and physiologically normal. J Am Coll Cardiol. 2004 Jun 2;43(11):2142-6. 

  17. S G De Biase, S F Fernandes, R J Gianini, J L Duarte. Vegetarian diet and cholesterol and triglycerides levels. Arq Bras Cardiol. 2007 Jan;88(1):35-9.

  18. Mann, J. and Truswell, A.S. eds., 2017. Essentials of human nutrition. Oxford University Press. P396.

  19. Anderson, J.W., Baird, P., Davis, R.H., Ferreri, S., Knudtson, M., Koraym, A., Waters, V. and Williams, C.L., 2009. Health benefits of dietary fiber. Nutrition reviews, 67(4), pp.188-205.

  20. Jew S, AbuMweis SS, Jones PJ. Evolution of the human diet: linking our ancestral diet to modern functional foods as a means of chronic disease prevention. J Med Food. 2009 Oct;12(5):925-34

  21. Wang F, Zheng J, dietYang B, Jiang J, Fu Y, Li D. Effects of vegetarian diets on blood lipids: a systematic review and meta-analysis of randomized controlled trials. J Am Heart Assoc. 2015;4(10): e002408. https://doi.org/10.1161/jaha.115.002408.

  22. Grundy SM, Cleeman JI, Merz CNB, et al. Implications of recent clinical trials for the National Cholesterol Education Program Adult Treatment Panel III Guidelines. J Am Coll Cardiol 2004;44(3):720–32.

  23. Melina, V.; Craig, W.; Levin, S. Position of the Academy of Nutrition and Dietetics: Vegetarian Diets. J. Acad.Nutr. Diet. 2016, 116, 1970–1980. [CrossRef] [PubMed]

  24. Agnoli, C.; Baroni, L.; Bertini, I.; Ciappellano, S.; Fabbri, A.; Papa, M.; Pellegrini, N.; Sbarbati, R.; Scarino, M.L.;

  25. Siani, V.; et al. Position paper on vegetarian diets from the working group of the Italian Society of Human Nutrition. Nutr. Metab. Cardiovasc. Dis. 2017, 27, 1037–1052. [CrossRef] [PubMed]

  26. BDA. British Dietetic Association Confirms Well-Planned Vegan Diets Can Support Healthy Living in People of All Ages. Available online: https://www.bda.uk.com/news/view?id=179 (accessed on 3 June 2019).

  27. Dietitians of Canada What You Need to Know About Following a Vegan Eating Plan—Unlock Food. Available online: https://www.unlockfood.ca/en/Articles/Vegetarian-and-Vegan-Diets/What-You-Need-toKnow-About-Following-a-Vegan-Eati.aspx (accessed on 4 October 2019).

  28. ADG. Australian Dietary Guidelines|NHMRC. Available online: https://www.nhmrc.gov.au/about-us/publications/australian-dietary-guidelines (accessed on 22 August 2019).

  29. Gomes, S.C.; João, S.; Pinho, P.; Borges, C.; Santos, C.T.; Santos, A.; Design, P.G.; Mendes De Sousa Editor, S. National Programme for the Promotion of Healthy Eating Guidelines for a Healthy Vegetarian Diet; Direção-Geral da Saúde: Lisbon, Portugal, 2015; ISBN 978-972-675-228-8.

  30. Anderson, L.U.S. Doctors Blast Belgian Misinformation on Vegan Diets. Available online: https://www.pcrm.org/news/news-releases/us-doctors-blast-belgian-misinformation-vegan-diets (accessed on 2 September 2019).

  31. World Economic Forum., 2015 https://www.weforum.org/agenda/2015/06/worlds-10-biggest-employers/ [accessed 25.06.2020].

  32. Kendall, C. W. C., & Jenkins, D. J. A. (2004). A Dietary portfolio: Maximal reduction of low-density lipoprotein cholesterol with diet. Current Atherosclerosis Reports, 6(6), 492–498. doi:10.1007/s11883-004-0091-9

  33. Phillips KM, Ruggio DM, Ashraf-Khorassani M. Phytosterol composition of nuts and seeds commonly consumed in the United States. J Agric Food Chem. 2005 Nov 30;53(24):9436-45.

  34. Brown L, Rosner B, Willett WW, Sacks FM. Cholesterol-lowering effects of dietary fiber: a meta-analysis.Am J Clin Nutr. 1999; 69:30–42. doi: 10.1093/ajcn/69.1.30

  35. Blanco Mejia, S., Messina, M., Li, S.S., Viguiliouk, E., Chiavaroli, L., Khan, T.A., Srichaikul, K., Mirrahimi, A., Sievenpiper, J.L., Kris-Etherton, P. and Jenkins, D.J., 2019. A meta-analysis of 46 studies identified by the FDA demonstrates that soy protein decreases circulating LDL and total cholesterol concentrations in adults. The Journal of nutrition, 149(6), pp.968-981.

  36. Sabaté J, Oda K, Ros E. Nut consumption and blood lipid levels: a pooled analysis of 25 intervention trials. Arch Intern Med. 2010 May 10;170(9):821-7. doi: 10.1001/archinternmed.2010.79. PMID: 20458092.

  37. Mensink, R.P., Zock, P.L., Kester, A.D. and Katan, M.B., 2003. Effects of dietary fatty acids and carbohydrates on the ratio of serum total to HDL cholesterol and on serum lipids and apolipoproteins: a meta-analysis of 60 controlled trials. The American journal of clinical nutrition, 77(5), pp.1146-1155.

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  39. Trumbo PR, Shimakawa T. Tolerable upper intake levels for trans fat, saturated fat, and cholesterol. Nutr Rev. 2011 May;69(5):270-8. doi: 10.1111/j.1753-4887.2011.00389.x.

  40. Brouwer, I. A., Wanders, A. J., & Katan, M. B. (2010). Effect of animal and industrial trans fatty acids on HDL and LDL cholesterol levels in humans--a quantitative review. PloS one, 5(3), e9434. https://doi.org/10.1371/journal.pone.0009434

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  44. Siri-Tarino, P. W., Sun, Q., Hu, F. B., & Krauss, R. M. (2010). Saturated fatty acids and risk of coronary heart disease: modulation by replacement nutrients. Current atherosclerosis reports, 12(6), 384–390. https://doi.org/10.1007/s11883-010-0131-6

  45. Melissa J Vincent, Bruce Allen, Orsolya M Palacios, Lynne T Haber, Kevin C Maki, Meta-regression analysis of the effects of dietary cholesterol intake on LDL and HDL cholesterol, The American Journal of Clinical Nutrition, Volume 109, Issue 1, January 2019, Pages 7–16, https://doi.org/10.1093/ajcn/nqy273

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