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Lowering Cholesterol with a Healthier Way of Eating

How is high cholesterol defined?

A total blood cholesterol level greater than 200 mg/dL, but less than 240 mg/dl, is considered by the American Heart Association (AHA)to be a moderately elevated cholesterol level. The AHA also considers this level to pose a borderline high risk to your health. Changes in diet and lifestyle are recommended for anyone with a total cholesterol level that falls into this range. A total blood cholesterol level greater than 240 mg/dL is considered to be high risk. This level carries with it a greater risk of heart attack, stroke, and coronary heart disease. If you total cholesterol falls into this upper range, you'll want to consult with your healthcare practitioner about the possibility of further lab tests or medications that can lower your total cholesterol level. Diet and lifestyle changes will still be extremely important if your cholesterol level falls into this upper range. However, these changes alone may or may not be enough to bring your cholesterol level back into a range that is agreed upon by you and your healthcare provider.

What are LDL and HDL?

Total cholesterol is not the only way - and not necessarily the best way - to evaluate your cholesterol status. Blood cholesterol can be broken down ("fractionated") into several types. These cholesterol types involve the various protein-containing molecules that transport cholesterol around the body. LDL (low-density lipoprotein) and HDL (high-density lipoprotein) are two of the best-studied transport molecules. LDL tends to carry cholesterol outward from the liver to the rest of the body tissue. This LDL cholesterol transporter is not capable of picking up cholesterol at various points around the body and bringing it back to the liver. The HDL transporter molecule is needed to carry out this "reverse" transport of cholesterol from tissue sites throughout the body back to the liver. Since this reverse transport of cholesterol back to the liver can help remove cholesterol from the bloodstream (and eventually from the body), HDL is considered a heart-protective transport molecule. Increasing your HDL level is most often a very helpful step in protecting the health of your heart.

How low should my LDL be?

The American Heart Association (AHA)recommends an LDL level of 100mg/dL or below as ideal. 130mg/dL is considered borderline high. Any LDL reading of 190mg/dL or above is considered very high.

How high should my HDL be?

An HDL level of 40-50mg/dL is considered average for an adult male according to the American Heart Association (AHA). For adult women, the corresponding range is 50-60 mg/dL. If your HDL is below 40 mg/dL, that level would definitely be considered too low by the AHA.

What's a good LDL:HDL ratio?

It lowers your risk of heart problems to keep your LDL:HDL ratio on the low side. A ratio at or below 3:1 (no more than three times as much LDL as HDL) is almost always recommended. It takes a ratio of 2.3:1 or below to put you significantly below average risk. It's also important not to confuse LDL:HDL ratio with total cholesterol:HDL ratio. This second type of ratio is also commonly used in cholesterol assessment. In the case of total cholesterol:HDL, a common goal is always to stay below 5:1. But a total cholesterol:HDL ratio of 4:1 would be even better, and a ratio of 3.5:1 is described as optimal by the American Heart Association.

If I have high cholesterol levels, can a healthy way of eating help me lower them into a normal range?

Absolutely! In fact, a study published in the July 2003 issue of the Journal of the American Medical Association in which a whole foods diet was compared head-to-head with treatment by statin drugs found the whole foods approach to be so effective that the Comment accompanying this JAMA article is entitled, "Diet first, then medication for hypercholesterolemia (high cholesterol)."

(For more discussion of recent studies see below: Research Studies Confirm the Importance of Healthy Foods and Healthy Cholesterol Levels.)

What foods may help me lower my LDL cholesterol and maintain or improve my ratio of LDL to HDL to healthier levels, e.g., 175 mg/dL with a 4:1 ratio of LDL:HDL ?

It's not just about counting cholesterol and calories from saturated fat in your diet that determines your cholesterol levels, but which foods you choose to eat, shows a study published in the May 2005 issue of the Annals of Internal Medicine.

The effects of two low-fat diets identical in total fat, saturated fat, protein, carbohydrate and cholesterol content-but differing in the amount of fruit and vegetables included-were compared in a group of 120 adults aged 30 to 65 with moderately high cholesterol levels. Both diets met American Heart Association Step I guidelines to obtain 30% of energy or less from total fat and 10% of energy or less from saturated fat.

One diet was typical of a low-fat U.S. diet, while the other incorporated considerably more vegetables, legumes, and whole grains.

After just four weeks, while those on typical low-fat diet dropped their total cholesterol 9.2 mg/dL and LDL cholesterol 0.18 mmol/L, study participants eating the low-fat diet rich in nutrient-dense plant-based foods saw their total cholesterol plummet 17.6 mg/dL and LDL 0.36 mmol/L.

The plant-rich diet dropped LDL more than twice as much as the conventional low-fat diet. Christopher Gardner, assistant professor of medicine at Stanford University, California, and lead author for the study, noted that doctors have just looked at what not to eat, and now need to emphasize health-promoting foods. "We were so focused on the negative-just what to avoid-and not what to include," he said.

In addition to a diet rich in fruits and vegetables and low in saturated fats, soluble fiber from foods such as oats, peas and beans (especially soy beans), has been found to lower elevated levels of LDL and improve the ratio of LDL to HDL.

Cold water fish, garlic and onions, olive oil and other sources of monounsaturated fats have also been shown to lower LDL, while cranberries, soy foods and niacin have been found to raise HDL.

Supplemental niacin has also been found to not only help reduce LDL levels, but to raise levels of protective HDL; however, it is important that you check with your health care practitioner before taking supplemental niacin for this purpose. Niacin is available in a number of different forms, one of which may be significantly more helpful for you than another. In addition, some forms of niacin may cause unpleasant flushing in some individuals. Your health care practitioner can help you maximize the benefits and minimize the potential side effects of supplemental niacin. If you want to lower your cholesterol levels or even if you've never had any problems with high cholesterol and just want to maintain healthy levels, enjoying a Healthier Way of Eating with the World's Healthiest Foods can help keep your cholesterol levels in check.

In fact, a review of human clinical studies conducted by Annie Lapointe and colleagues from Laval University in Quebec, and published in the February 2006 issue of the Journal of Nutritional Biochemistry has confirmed that following a Mediterranean-style diet, rich in olive oil, fruit and vegetables and fish-the diet recommended by the World's Healthiest Foods-is better than taking supplements to protect against cardiovascular disease.

Lapointe believes a Mediterranean-style diet is more effective against cardiovascular disease because a highly protective synergy occurs among the wide variety of dietary antioxidant vitamins, healthy monounsaturated fats, and flavonoid-rich foods this healthy food pattern supplies.

The synergistic effects produced by the combination of many antioxidant compounds and flavonoid-rich foods in a Mediterranean-style diet significantly reduce the susceptibility of LDL cholesterol to oxidation (free radical damage). Since only after LDL has been oxidized does it become involved in the development of atherosclerosis, this may help explain the cardiovascular benefits of the Mediterranean diet. In March 2005 in the Journal of Nutrition, Lapointe's team published research conducted in Quebec in which 71 healthy women were provided with nutrition information and helped to follow a Mediterranean diet for 12 weeks. By the end of the study, the women's blood levels of oxidized LDL had dropped by 11.3%.

Cholesterol is Not Inherently Bad for the Body:

In fact, without cholesterol, your body would be unable to make hormones, cell membranes or vitamin D. Normally, cholesterol flows through the blood vessels without causing any damage or the build-up of atherosclerotic plaques. It¡¯s only if cholesterol becomes oxidized by free radicals in the body that it can become problematic. That is why eating foods rich in antioxidants is so important. Foods rich in antioxidants, such as vitamins E, C and beta carotene, can help prevent the oxidation of cholesterol and the damage it may cause to blood vessels.

(For more information on cholesterol, see below: What is cholesterol, and why should I be concerned if my cholesterol levels are too high? What causes high cholesterol?)

EAT MORE:

Foods for Healthy Cholesterol Levels
Nutrient Foods Benefits
Soluble fiber* Whole grains, oat bran, barley, peas, beans (all types, especially soy), nuts Lowers LDL and improves ratio of LDL to HDL
Niacin* (if LDL levels are already high, supplements may be necessary to reduce levels) Salmon, tuna, chicken, calf liver, halibut, asparagus, crimini mushrooms Helps decrease the body's production and increase its elimination of cholesterol, prevents oxidation of LDL and can increase levels of HDL cholesterol
Vitamin E* Swiss chard, sunflower seeds, spinach, kale, mustard greens, almonds, walnuts Helps prevent prevent the oxidation of LDL cholesterol
Vitamin C* Citrus fruits, broccoli, red bell peppers, kale, Brussels sprouts, kiwifruit Helps prevent the oxidation of cholesterol
Flavonoids, including naringenin Citrus fruits, especially grapefruit Lowers LDL and triglycerides
Beta carotene* Carrots, sweet potatoes, winter squash, kale Helps prevent the oxidation of LDL cholesterol
Polyphenols, including pterostilbene Cranberries, grapes, blueberries,olive oil Help prevent oxidation of cholesterol and increase levels of HDL cholesterol
Phytosterols Sesame, pumpkin, sunflower seeds Help lower cholesterol
Unsaponifiables Brown rice Lowers LDL cholesterol
Foods rich in taurine and omega 3 fatty acids (e.g., cold water fish), monounsaturated fats (e.g., olive oil, avocado, walnuts, almonds) and the allium family of vegetables (e.g., garlic, onions) can also be helpful. These foods' cholesterol-lowering benefits are discussed below under "How Foods Help Lower Cholesterol".
Whole soyfoods, but not isolated soy protein or isoflavones, have also been shown to significantly lower LDL while raising HDL cholesterol.These studies are discussed below under "Research Studies Confirm the Importance of Eating Whole Foods on Healthy Cholesterol Levels."
Mediterranean Diet. Following a Mediterranean diet has been linked to lower levels of oxidized LDL and lower incidence of cardiovascular disease. This research is discussed below under "Research Studies Confirm the Importance of Eating Whole Foods on Healthy Cholesterol Levels."
*Click on link for a complete list of foods rich in these nutrients.

AVOID:

Saturated fats and cholesterol Red meat and other animal products Strong association with atherosclerosis and heart disease
Trans-fatty acids (hydrogenated fats) Margarine, coffee creamers, many processed foods Increase LDL cholesterol and lipoprotein(a) levels

Eating a Variety of Cholesterol-Lowering Foods Has Additive Beneficial Effect

A study published in the October 2004 issue of the British Journal of Nutrition underscores the additive beneficial effects that result when foods independently known to lower cholesterol are combined in a healthy way of eating. In this study of 12 patients with elevated LDL cholesterol levels, a diet containing soy protein, almonds and other nuts, plant sterols (also found in nuts), and soluble fiber (in high amounts in beans, oats, pears) reduced blood levels of all LDL fractions including small dense LDL (the type that most increases risk for cardiovascular disease) with near maximal reductions seen after only 2 weeks.

Combination of Cholesterol-Lowering Foods Drops LDL by More than 20%

A diet that includes a combination of cholesterol-lowering foods, such as soy, plant sterols, almonds and viscous fibers, can reduce LDL-cholesterol levels by 20% or even more, shows a follow up to the October 2004 study, which was published in the March 2006 issue of the American Journal of Clinical Nutrition.

This year-long study followed 55 volunteers with high cholesterol levels. Subjects ate a diet that, for every 1,000 calories, included one gram of plant sterols, 10 grams of viscous fiber, 22.5 grams of soy protein, and 23 grams of whole almonds.

Enriched margarines were used as the source of plant sterols (for whole food sources of plant sterols, see below), the fiber came from oats, barley, okra and eggplant, and the soy proteins came from soy milk and tofu. Participants were also instructed to eat five to ten daily servings of fruit and vegetables.

Regular blood tests during the year allowed the researchers to measure total cholesterol, triglycerides and HDL cholesterol levels. LDL levels were calculated from these results.

Average cholesterol reductions at 3 months and 1 year were 14% and 12.8, respectively-less than those observed after treatment with statins; however, 31.8% of study participants had reductions of LDL-cholesterol of more than 20% at 1 year, which is similar to results from statin therapy and equivalent to a 30% reduction in risk of death from heart disease.

HDL-cholesterol levels were also increased, and a small but significant 13% reduction in blood levels of triglycerides was noted. The researchers also reported a "small but statistically significant" loss of weight among the participants.

Those who best followed the dietary recommendations experienced the largest drops in LDL-cholesterol levels. Participants found it easiest to incorporate the almonds and plant-sterol margarine into their daily lives with 79% and 67% of volunteers, respectively, reaching the targets for their intake. Fiber and soy protein were more challenging since neither are found in most fast foods, so they require a little grocery list planning; their targets were reached a bit less, by 55% and 51%, respectively.

More than 30% of motivated participants who ate the dietary portfolio of cholesterol-lowering foods under real-world conditions were able to lower their LDL-cholesterol concentrations more than 20%, which was not significantly different from their response to a first-generation statin.

"The study's findings suggest that the average person can do a lot to improve their health through diet," said Jenkins.

Plant sterols are naturally occurring components of plant cell membranes just as cholesterol is a part of animal cell membranes. The three most abundant sterols are: ?-sitosterol, campesterol, and stigmasterol.

A word of caution about plant sterol-enriched margarines

Plant sterol-enriched margarines (such as Benecol or Take Control), can contain trans fats despite their claim to be trans fat-free. This misleading claim can legally be made because under the 2006 regulations that demand disclosure of trans fats, the FDA allows manufacturers to round to zero any ingredients that account for less than 0.5 grams per serving. (In the case of margarines, a limit of one half gram per tablespoon is applied). The new legislation also permits manufacturers to say "zero trans fats" on the label if the above standard has been met. If a person used 4 tablespoons of a sterol-enriched, "trans free" margarine over the course of a day (not only as a spread on toast or baked goods but in a recipe, for example), that person would be getting about 2 full grams of trans fat from this "trans free" product. To put that amount in perspective, a July 2002 report from the Institute of Medicine at the National Academy of Science declared that the upper limit for trans-fats in the diet should be zero. The consumption of 2-3 grams a day of trans fats increases the risk of coronary heart disease by 21%. It's important to be equally cautious about an enriched margarine that is truly trans free. Some enriched margarines in the marketplace advertise themselves as "trans free" and actually are trans free. (Smart Balance is one example). However, these enriched margarines usually become trans free by increasing their saturated fat percentage—not a recommended strategy from our perspective.

For those who would prefer to get their plant sterols from whole foods, these compounds are present naturally, although in smaller amounts than in sterol-enriched margarines, in all plant foods. The highest concentrations of plant sterols are found in unrefined vegetable oils, nuts, seeds, legumes, and whole grains.

In 2000, the FDA authorized a health claim describing the relationship between dietary intake of plant sterols and reduced risk of heart disease. That health claim states that "Foods containing at least 0.65 grams per serving of plant sterol esters, eaten twice a day with meals for a daily total intake of at least 1.3 grams, as part of a diet low in saturated fat and cholesterol, may reduce the risk of heart disease." As the table below shows, a healthy way of eating featuring daily selections from the whole foods listed below can easily deliver 1.3 grams of cardio-protective plant sterols.

Phytosterol Content of Selected Foods
Food Serving Phytosterols (mg)
Wheat germs 1 ounce 114-118
Sesame seed 1 ounce 133-138
Pumpkin seeds 1 ounce 88
Pistachio 1 ounce 90-96
Sunflower seeds 1 ounce 77-82.5
Unrefined Canola oil 1 TBS 91
Peanuts 1 ounce 62
Wheat bran 1/2 cup 58
Almonds 1 ounce 34
Brussels sprouts 1 ounce mg 34
Rye bread 2 slices 33
Macadamia nuts 1 ounce 33
Extra virgin olive oil 1 TBS 22

Want suggestions for some delicious cholesterol-lowering meals and recipes?

Just click here for our Atherosclerosis Meal Planner.

How do these foods help lower LDL cholesterol and maintain healthy levels?

Soluble Fiber:

Soluble fiber significantly reduces blood cholesterol levels by several different mechanisms:

First, soluble fiber in the intestines binds to bile from the liver, so the bile is carried out of the body as waste instead of being reabsorbed. In order for the body to make more bile, which is necessary for digestion, it must break down more cholesterol, removing it from the bloodstream. In addition, because bile is needed for the absorption of cholesterol from food, binding the bile makes it less able to assist in cholesterol absorption, so less dietary cholesterol is absorbed from food as well.

Secondly, when normal levels of bacteria are present in the colon, they are able to break down some of the soluble fiber into what are called short-chain fatty acids. In addition to being the preferred fuel of colon cells and thus essential for good colon and digestive health, some short-chain fatty acids are absorbed into the bloodstream, where they travel to the liver and decrease the action of HMG Co-A reductase, one of the main enzymes involved in the production of cholesterol.

Diets high in soluble fiber have been shown in some studies to lower total cholesterol and LDL cholesterol as much as 20-30%. The soluble fiber used in these studies was the naturally-occurring fiber found in oat bran, beans, and other food sources. In these same studies, the use of cooked soy beans, a rich source of both soy protein and naturally occurring soluble fiber, led to a decrease in total cholesterol of 30% and a decrease in LDL cholesterol of 35-40%.

(For more information, see below: Research Studies Confirm the Importance of Eating Healthy Foods on Healthy Cholesterol Levels.)

Cultures in which soy foods constitute a major portion of the diet typically have much lower rates of heart disease than cultures with a low consumption of soy. In addition to this epidemiological data, clinical studies have shown that soy foods are protective against the development of heart disease and its associated mortality. The beneficial effects found in these studies are due to an intake of whole soy foods and not the isolated soy components that are currently available in supplement form. Soybeans and foods made from them have been found to significantly decrease the risk of heart disease and heart attack via several mechanisms. Soy can help prevent the oxidation of LDL cholesterol and soy foods have been shown to decrease LDL by 35-40% and total cholesterol levels by 30%, to decrease triglyceride levels, and to decrease platelet aggregation reducing the risk of blood clots. Soy foods may also increase levels of HDL (beneficial) cholesterol.

Research presented at the 2004 annual meeting of the North American Menopause Society held October 6-9, 2004 in Washington, D.C., and a study published in the November 2004 issuye of the American Journal of Clinical Nutrition suggest that soy offers special cholesterol-lowering benefits for premenopausal women: the isoflavones in soy appear to work with a woman's own estrogen to decrease cholesterol and increase bone mass. For a summary of this research, see below: Research Studies Confirm the Importance of eating Healthy Foods on Healthy Cholesterol Levels.)

For more information about soy, click Soybeans.; on fiber, click Dietary Fiber.

Niacin:

Niacin, also known as vitamin B3, has been shown to decrease the activity of HMG Co-A reductase, a primary rate-limiting enzyme involved in the production of cholesterol, thus causing a decrease in the body¡¯s production of cholesterol. Niacin also helps increase the breakdown of cholesterol to bile, decreases the proliferation of smooth muscle cells, helps to prevent LDL oxidation, reduces platelet clumping, lowers lipoprotein(a) levels, and can increase levels of HDL by as much as 15-40%. Increasing HDL levels, particularly through diet, can significantly decrease atherosclerosis progression.

Niacin has been shown to decrease cholesterol levels by 10-26% and to decrease heart attack recurrence by 29%. Niacin given to patients after a heart attack reduced non-fatal heart attack recurrence by 27% and decreased long-term overall mortality by 11%.

For more information, click Niacin.

Vitamin E:

Vitamin E prevents oxidation of LDL cholesterol, prevents the growth of blood vessel plaques, and has been shown to reduce the risk of heart attack and deaths related to heart disease.

The primary fat-soluble antioxidant in the body, Vitamin E is the antioxidant found in highest quantities in LDL cholesterol particles, which it protects from oxidation. As the main antioxidant defender of lipids (fats) in the body, Vitamin E is responsible for putting a halt to chain reactions of lipid peroxidation anywhere in the body.

Vitamin E has also been shown to decrease platelet clumping, prevent the rupture of existing atheromas, decrease the migration of macrophages to atheromas, prevent the inhibition of nitric oxide production, and to decrease the expression of adhesion molecules on the surfaces of endothelial cells (which form the outermost layer of blood vessel walls), thereby reducing the amount of binding that can occur with monocytes and other immune cells.

(For more information, see below: Research Studies Confirm the Importance of Eating Healthy Foods on Healthy Cholesterol Levels.)

Why whole foods are better than vitamin E supplements:

The potential downside of taking vitamin E as a supplement is that large amounts have been associated with a possible increase in oxidation. This is because, in order to prevent the oxidation of fats, the vitamin E itself must become oxidized. If all of the vitamin E in an LDL particle becomes oxidized, it is then able to cause oxidation of the LDL cholesterol. A way to prevent this from happening is to make sure that enough of the antioxidant vitamin C is available. Vitamin C is very effective at restoring oxidized vitamin E back to its non-oxidized, antioxidant form. For this reason, studies recommend that an increase in vitamin E intake be accompanied by an increase in vitamin C intake.

One more caution for those interested in taking supplemental vitamin E. Because of its ability to decrease platelet clumping and clot formation, supplemental vitamin E should not be used by those taking blood thinners unless they are being closely monitored by their doctor. Getting your vitamin E from foods, however, is highly unlikely to cause such problems. Just remember to include foods rich in vitamin C (discussed next) in your meals as well.

Vitamin C:

The body's primary water-soluble antioxidant, vitamin C is needed for the proper function of blood vessels, regenerates vitamin E, and can help decrease cholesterol levels through several mechanisms. Although vitamin C is not found in LDL cholesterol particles because it is not fat-soluble, it does play a large role in the prevention of LDL oxidation. In addition to restoring antioxidant function to vitamin E, vitamin C also eliminates many free radicals produced by normal body metabolism, thus preventing them from damaging cholesterol.

Low levels of vitamin C have also been associated with higher levels of total cholesterol and LDL cholesterol, and lower levels of HDL cholesterol. Vitamin C is required for the breakdown of cholesterol to bile in the liver and also for the uptake of LDL cholesterol into cells for normal use. Vitamin C use is therefore associated with a decrease in total and LDL cholesterol levels as well as an increase in HDL levels. These effects seem to be most pronounced in men and tend to take about six months of increased vitamin C intake to be significant.

Low vitamin C levels are associated with an increase in cholesterol deposition in the aorta, the main artery leaving the heart. Vitamin C has been shown to decrease the binding of monocytes to atheroma lesions, thereby reducing the rate of atheroma growth. It is especially beneficial in preventing the negative effects of smoking on the blood vessels and heart. Vitamin C also reduces the deactivation of nitric oxide (a chemical messenger that tells blood vessels to dilate) and actually increases its production, leading to decreased vessel spasm and increased vasodilation.

For more information, click Vitamin C and see below, Research Studies Confirm the Importance of Eating Healthy Foods on Healthy Cholesterol Levels.)

Beta Carotene:

Beta-carotene is another antioxidant found in foods. Although it is not found in high quantities in LDL cholesterol particles, it has been shown to prevent the oxidation of LDL cholesterol. Beta-carotene, like vitamin C, is also able to increase vessel dilation and reduce vessel spasm. One study has shown that patients with the lowest level of beta-carotene intake had almost twice the risk of having a heart attack compared to those with the highest intake. The group of patients taking the highest intake of beta-carotene had about 1/3 the risk of fatal heart attack and about 1/2 the risk of cardiovascular death as those in the group with the lowest intake.

For more information, click beta-carotene and see below LDL Cholesterol Protected by Beta-Carotene.)

Taurine:

Fish are the best sources of taurine. Cold-water fish such as salmon and cod are recommended as these are also rich in beneficial omega-3 essential fatty acids. Taurine is an amino acid component of protein particularly common in fish protein. It has been shown to decrease elevated cholesterol levels by decreasing the absorption of cholesterol in the intestines in addition to increasing the conversion of cholesterol into bile, thereby removing it from the body. Studies have shown that individuals with higher intakes of taurine have a lower risk of death from ischemic heart disease. To gain the maximum protective benefit, eat a serving of fish at least 5 days a week.

For more information about fish, serving ideas and recipes, click cod, halibut, salmon, scallops, shrimp, snapper, yellowfin tuna

Foods Rich in Omega-3 Fatty Acids

Best Food Sources of Omega-3 Fats: cold-water fish such as salmon and cod and their oils, flaxseed and its oil, walnuts, and purslane.

Frequent consumption of fish, especially cold water fish since these contain the most omega-3s, is associated with a decreased risk of heart attack. A high intake of omega-3 fats, when part of a diet low in saturated fat, has also been found to help decrease cholesterol. Foods rich in omega-3s should be used to replace foods high in saturated fats such as meat and dairy products.

Monounsaturated Fats:

Best Food Sources of Monounsaturated Fats include: olive oil, high oleic sunflower oil, avocado, almonds, cashews, peanuts, sesame seeds, pumpkin seeds and walnuts.

Monounsaturated fats are a unique type of fat found in particularly high quantities in olive oil. These stable fats decrease the oxidation of LDL cholesterol, help reduce cholesterol levels, and may partly explain why the ¡°Mediterranean Diet,¡± which is high in monounsaturated fats as well as whole foods, is protective against heart disease.

Studies have revealed that populations that follow the ¡°Mediterranean¡± diet, which is high in vegetables and whole grains, and low in saturated fats, but relatively high in total fat due to a high intake of olive oil, tend to have fairly low rates of cardiovascular disease and its associated mortality. Based on studies of fat intake and heart disease in many countries, it would be expected that these populations would have high rates of heart disease because of the level of fat in their diets. However, the opposite is true.

Recent studies have shown that LDL cholesterol particles that contain monounsaturated fats, such as from olive oil, are much more resistant to oxidation that those that contain high levels of polyunsaturated fats, such as from other vegetable oils like corn or safflower oil. In addition, the substitution of monounsaturated fats for saturated fats in the diet has been shown to decrease total cholesterol by 13.4% and to decrease LDL cholesterol by 18%.

The most important aspect of the use of monounsaturated fats is that they be used in place of saturated fats. Adding olive oil to a diet that is already high in saturated and/or trans fats can have negative effects on heart disease progression and risk. Olive oil should instead be used to replace animal sources of fat and other vegetable oils. Even though olive oil is a relatively stable fat, it is important not to use olive oil when cooking foods as high temperatures. Exposing even this more stable oil to high temperatures may cause it to oxidize. Instead, use our Healthy Sauté or Healthy Stir Fry to cook the food, then after removing it from the heat, add the olive oil. You'll add all its delicious flavor and health-giving benefits to your food, without potentially adding damaged fats that might cause damage to the fats, including cholesterol, in your own body.

Polyphenols, including Pterostilbene
Pterostilbene, a powerful antioxidant compound found in cranberries, grapes and blueberries, activates a type of cell receptor involved in absorbing lipids, including cholesterol, into cells for use in energy production. A study published in the July 2004 issue of the Journal of Agricultural and Food Chemistry found that pterostilbene was as effective as the lipid-lowering drug ciprofibrate in activating this cell receptor, called PPAR-alpha. (For more on this research see below: Research Studies Confirm the Importance of Eating Healthy Foods on Healthy Cholesterol Levels.

Olive Oil Polyphenols Primarily Responsible for Olive Oil's Cardiovascular Benefits

Researchers now believe the abundance of polyphenols in extra virgin olive oil, rather than its monounsaturated fatty acids, are largely responsible for the oil's well known cardiovascular benefits.

And its rich supply of polyphenols, which are known to have anti-inflammatory, antioxidant and anticoagulant actions, may also be central to emerging evidence that olive oil's protective effects extend to colon cancer and osteoporosis.

Research conducted by Dr. Juan Reno and colleagues at the Reina Sofia University Hospital, Cordoba, Spain, and published in the November 2005 issue of the Journal of the American College of Cardiology, investigated the effects of virgin olive oil on endothelial function in 21 volunteers with high cholesterol levels.

The endothelium, although just a one-cell thick layer of flat cells that lines the inner wall of all blood vessels, may be the critical player in cardiovascular health. Among its many functions, the endothelium orchestrates the mechanics of blood flow, and regulates blood clot formation and the adhesion of immune cells to the blood vessel wall (one of the first steps in the formation of plaque).

Normally, after a meal, endothelial function is impaired for several hours. Blood vessels become less elastic, and blood levels of free radicals potentially harmful to cholesterol (lipoperoxides and 8-epi prostaglandin-F2) rise.

But when the subjects in this study ate a breakfast containing virgin olive oil with its normal high phenolic content (400 ppm), their endothelial function actually improved, blood levels of nitric oxide (a blood vessel-relaxing compound produced by the endothelium) increased significantly, and far fewer free radicals were present than would normally be seen after a meal.

When they ate the same breakfast containing the same type of virgin olive oil with its phenolic content reduced to 80 ppm, the beneficial effects were virtually absent, and concentrations of cholesterol-damaging free radicals increased. The results of this study underscore the importance of knowing how to select, store and serve your olive oil to maximize its polyphenol content. For all the information you need, see our How to Select and Store section in Olive oil.

Phytosterols

Phytosterols are compounds found in plants that have a chemical structure very similar to cholesterol, and when present in the diet in sufficient amounts, are believed to reduce blood levels of cholesterol, enhance the immune response and decrease risk of certain cancers.

Phytosterols beneficial effects are so dramatic that they have been extracted from soybean, corn, and pine tree oil and added to processed foods, such as "butter"-replacement spreads, which are then touted as cholesterol-lowering "foods." But why settle for an imitation "butter" when these spreads contain hydrogenated fat (see "A word of caution about plant-sterol enriched margarines" above) and Mother Nature's nuts and seeds are a naturally rich source of hydrogenated fat-free phytosterols-plus cardio-protective fiber, minerals and healthy fats as well?

In a study in the November 2005 issue of the Journal of Agricultural and Food Chemistry, researchers published the amounts of phytosterols present in nuts and seeds commonly eaten in the United States.

Sesame seeds had the highest total phytosterol content (400-413 mg per 100 grams), and English walnuts and Brazil nuts the lowest (113 mg/100grams and 95 mg/100 grams). (100 grams is equivalent to 3.5 ounces.) Of the nuts and seeds typically consumed as snack foods, pistachios and sunflower seeds were richest in phytosterols (270-289 mg/100 g), followed by pumpkin seeds (265 mg/100 g).

Allium Family Vegetables:

Best Sources of Allium Vegetable Compounds: Fresh, raw garlic and onions contain the highest amounts of these beneficial compounds.

Allium family vegetables contain compounds that have been shown to modestly lower total cholesterol levels, lower blood pressure in cases of hypertension, and slow the rate of plaque growth. One of these compounds, S-propyl cysteine, has been shown to decrease the liver cells¡¯ secretion of apolipoprotein B100 (apo B-100). Apo B 100 is virtually the only protein component of LDL, which is composed of both protein and cholesterol. Apo B-100 is that portion of the LDL molecule that allows it to bind to receptors on other molecules, such as those that make up the lining of the blood vessels. Having a high level of apo B-100 in the blood is therefore a potent risk factor for developing cardiovascular disease.

Other S-Alk(en)yl cysteines found in garlic have been shown to inhibit cholesterol synthesis by lowering the activity of HMG-CoA reductase 30-40%. Garlic incorporated into high fat diets in animal studies has significantly decreased lipid peroxidation (damage to fats such as cholesterol) and the activity of a number of enzymes involved in cholesterol synthesis including HMG CoA reductase.

In a randomized, double-blind, placebo-controlled study involving men with high cholesterol, total cholesterol was lowered 7% and LDL cholesterol 10% among those given aged garlic extract, and in animals receiving garlic, blood levels of total cholesterol and triglycerides dropped by 15 and 30% respectively. In later test tube studies using cultured rat liver cells, garlic, specifically its water-soluble sulfur compounds, was found to inhibit cholesterol synthesis 44-87%. Of all these compounds, S-allylcysteine, was the most potent inhibitor of cholesterol synthesis. In other test tube studies, evidence has been presented that shows several garlic compounds can effectively suppress the oxidation of LDL, and in human subjects, short-term supplementation of garlic has been shown to increase their LDL's resistance to oxidation.

What foods should I consume sparingly or avoid to promote healthy cholesterol levels?

Saturated Fat and Cholesterol

Excessive dietary intake of foods rich in saturated fat and cholesterol, which are found primarily in meat, particularly red meat, and other animal products, is strongly associated with increased risk of atherosclerosis and heart disease.

Iron

High levels of stored iron are associated with increased free radical production and therefore increased risk of heart attack, especially in individuals with high cholesterol levels.

Hemochromatosis, a condition of iron overload, is common in Caucasian males.

Iron is a transitional metal that can catalyze the formation of free radicals called hydroxyl radicals, which can damage cholesterol and have been linked to cardiovascular disease. Recent studies suggest that the heme-iron from red meat is more likely to produce hydroxyl radicals than the heme-iron in chicken, fish or vegetarian sources of protein (e.g., beans, nuts and seeds, eggs, and low fat dairy products). Using these sources of protein as your dietary staples and limiting red meat consumption is therefore recommended.

Trans-Fatty Acids (Hydrogenated Fats)

Trans fats are so-called since their chemical structure is the mirror opposite of that found in vegetable oils. These abnormally structured fats can be made from vegetable oils by subjecting them to a chemical process that transforms them into solid fats. Also called hydrogenated fats, trans fats increase LDL cholesterol and lipoprotein(a) levels, may be more damaging to the heart and blood vessels than saturated fat, and should be eliminated from the diet. These unnatural fats are virtually absent from whole foods, but are the predominant component in margarine and are frequently added to processed foods, baked goods, coffee creamers, and snack foods.

Vitamin D

Although necessary for bone strength, excessive amounts of vitamin D are associated with plaque build-up, especially in those with low magnesium intake. Increase magnesium intake rather than avoid vitamin D-rich foods such as salmon, tuna, liver, eggs and milk; these foods provide numerous important health benefits. Excellent sources of magnesium include Swiss chard and summer squash. Very good sources include spinach, turnip greens mustard greens, pumpkin seeds, broccoli, , flax seeds, green beans, collard greens, kale, sunflower seeds, sesame seeds, quinoa, buckwheat, salmon, and black beans.

An Egg a Day May Be Okay

Although eggs are well-known for containing cholesterol, in two recent studies, participants' blood levels of total cholesterol, LDL cholesterol, HDL cholesterol, and triglycerides were not affected by eating an egg a day.

Enjoying a daily egg-whose yolk is a rich source of vision-protective carotenoids, including not only lutein but also zeaxanthin-may reduce the risk of developing age-related macular degeneration (AMD) without increasing cholesterol levels, according to the results of these two studies, published in the October 2006 Journal of Nutrition.

Conducted at the University of Massachusetts, these studies show that, in addition to keeping hunger at bay longer (eggs' satiety index is 50% than that of most breakfast cereals), an egg a day boosts blood levels of lutein and zeaxanthin, thus reducing the risk of AMD-without increasing cholesterol or triglyceride levels.

In AMD, the macula, the central part of the retina which controls fine vision, deteriorates, greatly limiting eyesight or even resulting in blindness in those afflicted. The leading cause of blindness in people over age 50, AMD afflicts more than 10 million people in the United States, plus an additional 15 to 20 million worldwide.

In the first study, a randomized cross-over trial, Elizabeth Goodrow and her team investigated the effects of eating one egg a day on blood levels of lutein, zeaxanthin, cholesterol and triglycerides in 33 men and women over age 60.

After a no-egg start up week, volunteers ate either an egg or egg substitute daily for 5 weeks, then again ate no eggs for a week before crossing over to the other intervention for a second 5 weeks.

After the 5-week period in which they ate a daily egg, participants' blood levels of lutein and zeaxanthin significantly increased by 26 and 38%, respectively, compared to their levels of these carotenoids after their no-egg week.

And although eggs are well-known for containing cholesterol, participants' blood levels of total cholesterol, LDL cholesterol, HDL cholesterol, and triglycerides were not affected by eating an egg a day.

In the second study, researchers led by Adam Wenzel looked at the effect of a 12-week egg intervention on lutein and zeaxanthin levels in both the blood and the retina of the eye (the macular pigment optical density or MOPD) of 24 women ranging in age from 24 to 59.

The women were randomly assigned to eat 6 eggs every week containing either 331 micrograms (Egg1) or 964 micrograms (Egg2) of lutein and zeaxanthin per yolk, or a placebo (a sugar-filled pill).

No changes in cholesterol levels were seen in the women eating eggs, but in those given the placebo (the sugar pill), increases in total cholesterol and triglycerides were recorded.

Unlike the first study, only blood levels of zeaxanthin, but not lutein, increased in both Egg1 and Egg2 groups; however, carotenoid levels in the retina (MPOD) increased in both egg intervention groups, a result that suggests a daily egg offers protection against AMD.

Although egg yolk contains less lutein and zeaxanthin than some other foods-spinach, for example-when supplied by eggs, these carotenoids appear to be especially well absorbed into the retina. "Increasing egg consumption to 6 eggs per week may be an effective method to increase MPOD," wrote lead study author Wenzel.

So, enjoy a quick and easy, appetite-satisfying, vision-sustaining poached or soft boiled egg for breakfast. Take an egg salad sandwich to work or add a hard boiled egg to your luncheon salad. On the weekend, treat yourself to our Healthy Breakfast Frittata or Egg Crepes filled with veggies, one of the delicious egg recipes featured in The World's Healthiest Foods Essential Guide. We suggest choosing organic omega-3-rich eggs if available. Produced by hens fed a diet rich in flaxseed, these eggs are an exceptional source not only of lutein and xeaxanthin, but cardio-protective anti-inflammatory omega-3 essential fatty acids as well.

Research Studies Confirm the Importance of Eating Healthy Foods on Healthy Cholesterol Levels

Combining Cholesterol-Lowering Foods as Effective as Statin Drugs

If you have high cholesterol, chances are your physician has suggested a statin drug to reduce your blood levels of LDL (bad) cholesterol. Statin drugs work by blocking the enzyme HMG-CoA reductase, which is involved in the body's production of cholesterol. Although statins are effective in lowering LDL, they have numerous side effects.

Well-known lesser side effects of statin drugs include nausea, diarrhea, constipation, muscle aches, pains and weakness. In some individuals, statin use causes an increase in liver enzymes, indicating abnormal liver functioning. If the increase is only mild, your doctor will likely tell you to continue taking the drug; if it is too abnormal, you'll be told to stop, which usually reverses the liver problem.

More serious potential side effects include rhabdomyolysis-severe muscle pain accompanied by the destruction of muscle cells. When this occurs, the muscle cells release a protein called myoglobin into the bloodstream. Myoglobin can impair kidney function and lead to kidney failure.

Lesser known side effects include changes in memory, attention, or concentration, irritability and depression, and a higher risk of suicide and accidents.

Perhaps the most important side-effect of statin drugs, which is likely a contributor to many of the above noted side effects, is that all statins deplete the body of CoQ10, a critically important antioxidant enzyme in our cells' energy production process. Our bodies produce CoQ10 using the same biochemical pathway that creates cholesterol, including the enzyme HMG-COA reductase, which statin drugs block.

Since muscle cells, especially heart muscle cells, and brain cells are those that use the most energy, adequate supplies of CoQ10 are essential for health. It's not surprising that statin drugs are accompanied by an increased risk of muscle pain, wasting and heart failure.

Fortunately, a study published in the February 2005 issue of the American Journal of Clinical Nutrition shows that dietary approaches combining cholesterol-lowering foods offers another option to statin drugs.

In this study, 34 patients with high cholesterol underwent three 1-month treatments in random order: a very-low-saturated-fat diet (the control diet), the same diet plus 20 mg lovastatin daily (statin diet), and a diet high in plant sterols, which included soy-protein foods (soy milks and soy burgers), almonds, oats, barley, psyllium, okra and eggplant (portfolio diets).

During each of the three diets, fasting blood samples were taken at weeks 2 and 4.

The results? All 3 diets lowered total cholesterol, which dropped an average of 8.5 on the control diet, 33.3 on the statin diet, and 29.6 on the portfolio diet after 4 weeks. However, the portfolio diet lowered LDL cholesterol as well as the statin diet, and nine study participants (26%) achieved their lowest LDL cholesterol level while on the portfolio diet. Given the risks-and expense-associated with statin drugs, if you have high cholesterol, ask your doctor about a month's trial to see if a dietary approach combining cholesterol-lowering foods can lower your LDL cholesterol as well as a statin drug.

Flaxseeds Cholesterol-Lowering Effects Comparable to Statins

In a study involving 40 patients with high cholesterol (greater than 240 mg/dL), daily consumption of 20 grams of ground flaxseed was compared to taking a statin drug. After 60 days, significant reductions were seen in total cholesterol, LDL cholesterol, triglycerides and the ratio of total to HDL cholesterol-in both groups. Those receiving flaxseed did just as well as those given statin drugs!

Body mass index, total cholesterol, HDL-cholesterol, LDL-cholesterol, triglycerides, and the ratio of total cholesterol/HDL-cholesterol were measured at the beginning of the study and after 60 days.

In those eating flaxseed, significant reductions were seen in total cholesterol (-17.2%), LDL-cholesterol (-3.9%), triglycerides (-36.3%) and the ratio of total cholesterol/HDL-cholesterol (-33.5%) were observed in the diet+flax group, compared to baseline. Similar reductions were seen in those taking the statin. Benefits did not significantly differ between the two groups.

LDL Cholesterol Lowered by a Whole Foods Diet:

In a landmark study, the effects of consuming a diet high in vegetables, fruits, soy foods and nuts were compared to either a control diet that was very low in saturated fat and based on milled whole-wheat cereals and low-fat dairy foods or the same diet plus the statin drug, lovastatin. Study participants, a group of 46 adults (25 men and 21 postmenopausal women with high cholesterol whose average age was 59) were randomly assigned to follow one of these three diets for one month. At the end of the month, all three groups showed a decrease in LDL (bad) cholesterol and C-reactive protein (a marker of inflammation that is a risk factor for cardiovascular disease).

In those on the control diet, LDL dropped an average of 8%, and C-reactive protein dropped an average of 10%.

In those on the whole foods diet, LDL dropped an average of 28.6%, and C-reactive protein dropped an average of 28.2%. In those on the control diet plus lovastatin, LDL dropped an average of 30.9%, and C-reactive protein dropped an average of 33.3%.

No matter your age, education, smoking status or physical activity, the more fruits and vegetables you eat, the lower your blood level of LDL (potentially harmful) cholesterol, suggests research from the National Heart, Lung, and Blood Institute published in the February 2004 issue of the American Journal of Clinical Nutrition. Researchers used data from the Family Heart Study to compare the amount of fruits and vegetables consumed to LDL levels in 4,466 men and women ranging in age from 37 to 66. The higher participants¡¯ intake of fruits and vegetables, the lower their LDL levels. Participants who ate the most produce (4 or more servings a day) had LDL levels about 7% lower than those who ate the least (0 to 1.9 servings daily).

Mediterranean Diet Boosts Antioxidant Levels, Protects LDL Cholesterol

Following a Mediterranean diet has been linked to lower incidence of cardiovascular disease and cancer. A study published in the September 2005 issue of the American Journal of Clinical Nutrition, reveals one reason why: people who enjoy a Mediterranean diet have much higher levels of protective antioxidants.

During 2001-2002, Greek researchers studied a random sample of 1514 men and 1528 women aged 18-89 years. Those most closely adhering to a Mediterranean diet had, on average, 11% higher antioxidant levels than those not following this healthy way of eating.

The beneficial effects of enjoying a Mediterranean diet were directly reflected in study participants' levels of oxidized LDL cholesterol (LDL damaged by free radicals, which contributes to the development of cardiovascular disease). Those most closely following a Mediterranean diet had, on average, 19% less oxidized LDL cholesterol than those whose diets least incorporated the olive oil, fruits and vegetables for which the Mediterranean diet is renowned. Additional analysis revealed that higher antioxidant levels were directly linked to consumption of olive oil, fruits and vegetables. Consumption of red meat, however, was associated with lower antioxidant capacity.

Mediterranean Diet Lowers Heart Disease Risk More than Low-Fat Diet

In just 3 months, eating a Mediterranean-style diet can reduce risk of heart disease by 15%--almost twice as much cardiovascular risk reduction as that seen on a low-fat diet-shows the Mediterranean Diet, Cardiovascular Risks and Gene Polymorphisms (Medi-RIVAGE) study.

Published in the November 2005 issue of the American Journal of Clinical Nutrition, this is the latest in a string of studies to affirm the benefits of this healthy way of eating.

French researchers assigned 212 men and women at moderate risk for heart disease to either a Mediterranean diet or a low-fat diet for 3 months.

Mediterranean diet participants were instructed to base their meals around whole grains, fruits, vegetables, nuts, and olive oil, and to eat fish 4 times a week, but red meat only once a week.

Those on the low-fat diet were told to eat poultry rather than beef, pork and other mammal meats, to eat fish 2-3 times a week, to stay away from animal products high in saturated fat, and to eat fruit, vegetables, low-fat dairy products and vegetable oils.

Among those on the Mediterranean diet, total cholesterol dropped by 7.5% compared to 4.5% in the low-fat diet group.

Overall cardiovascular disease risk fell 15% on the Mediterranean diet compared to 9% on the low-fat diet.

The Medi-RIVAGE study suggests that the healthy fats found in a Mediterranean-style diet-such as the healthy way of eating espoused at the World's Healthiest Foods-not only do not promote heart disease, but lower cardiovascular disease risk. And these fats-the monounsaturated fats in olive oil, omega 3 fats in fish, and mono- and polyunsaturated fats in nuts-not only lower your risk of heart disease but greatly improve the flavor and taste of your food while also increasing satiety (feeling satisfied after eating, so you are much less likely to eat more than you need).

Pterostilbene, in Cranberries, Blueberries and Grapes, Lowers Cholesterol

Pterostilbene (pronounced TARE-oh-STILL-bean), a powerful antioxidant compound found in grapes, cranberries and blueberries, which is already known to fight cancer, may also help lower cholesterol.

In a study using rat liver cells, scientists at the USDA Agricultural Research Service compared the cholesterol-lowering effects of pterostilbene to those of ciprofibrate, a lipid-lowering drug, and resveratrol, another antioxidant found in grapes with a chemical structure similar to pterostilbene that has been shown to help fight cancer and heart disease.

They based their comparison on each compound's ability to activate PPAR-alpha (short for peroxisome proliferator-activated receptor alpha). The PPARs are a family of receptors on cells all throughout the body that are involved in the absorption of compounds into cells for use in energy production. PPAR-alpha is crucial for the metabolism of lipids, including cholesterol. Pterostilbene was as effective as ciprofibrate and outperformed resveratrol in activating PPAR-alpha. The take away message: turn up your cholesterol burning machinery by eating more grapes, blueberries and cranberries.

Grape polyphenols lower key factors for coronary heart disease in women

Consuming a drink made from adding just 36 g (1.26 ounces) of a powder made from freeze-dried grapes to a glass of water daily for 4 weeks resulted in a wide variety of cardioprotective effects in 24 pre- and 20 postmenopausal women, shows a study published in the August 2005 issue of the Journal of Nutrition.

The rich mixture of phytonutrients found in grapes-which includes flavans, anthocyanins, quercetin, myricetin, kaempferol, as well as resveratrol-is thought to be responsible for these numerous protective effects on cholesterol metabolism, oxidative stress (free radical activity) and inflammation.

Grapefruit lowers cholesterol, heart disease risk

Both blond and red grapefruit can reduce blood levels of LDL (bad) cholesterol, and red grapefruit lowers triglycerides as well, shows a study published in the March 2006 issue of the Journal of Agricultural and Food Chemistry.

Israeli researchers from the Hebrew University in Jerusalem first tested the antioxidant potential of blond and red grapefruits and then their cholesterol-lowering potential in humans. The test tube research showed that red grapefruit contains more bioactive compounds and total polyphenols than blond, but both grapefruits are comparable in their content of fiber, phenolic and ascorbic acids, and the flavonoid, naringinen, although red grapefruit contains slightly more flavonoids and anthocyanins.

When consumed daily by humans, both grapefruits appear to lower LDL cholesterol in just 30 days. Blood cholesterol levels were measured at the outset of the trial period and after 30 days in 57 patients, aged 39-72 years, with high cholesterol. These subjects were randomly divided into three equal groups. Those in the first group added red grapefruit to their daily diet; those in the second group supplemented their diet with blond grapefruit, and the third group, acting as a control, ate no grapefruit.

After 30 days, cholesterol levels in both the red and blonde grapefruit groups had dropped significantly: total cholesterol by 15.5% in those eating red grapefruit and 7.6% in those eating blond grapefruit; LDL cholesterol by 20.3% and 10.7% respectively; and triglycerides by 17.2% and 5.6% respectively. No changes were seen in the control group.

Both red and blond grapefruits both positively influenced cholesterol levels, but red grapefruit was more than twice as effective, especially in lowering triglycerides. In addition, both grapefruits significantly improved blood levels of protective antioxidants. Red grapefruit's better performance may be due to an as yet unknown antioxidant compound or the synergistic effects of its phytonutrients.

In response to this rapid and very positive outcome, the researchers concluded that adding fresh red grapefruit to the diet could be beneficial for persons with high cholesterol, especially those who also have high triglycerides. One caveat, however: Compounds in grapefruit are known to increase circulating levels of several prescription drugs including statins. For this reason, the risk of muscle toxicity associated with statins may increase when grapefruit is consumed. (See our grapefruit Safety section for more information.)