Heart and blood vessel (cardiovascular) disease is the number one killer of Americans, and study after study points to elevated cholesterol as a major contributor to the problem. Some authorities have indicated that for every one-percentage point that cholesterol levels are reduced, the risk for cardiovascular disease is reduced by two points. In addition, most people with diabetes have increased risk for heart disease and stroke, due in part to high cholesterol and triglyceride levels, which can result in death. In fact, more than 65 percent of people with diabetes die from heart disease or stroke. By managing diabetes, and blood lipids (cholesterol and triglycerides), however, diabetics can greatly reduce this risk.1

The current conventional medical treatment is cholesterol- lowering prescription drugs, along with low saturated fat diets. In addition, it makes sense to work with your doctor in trying one or more of the following relatively risk-free dietary supplement approaches as part of your total program for lowering cholesterol and reducing risk of cardiovascular disease.

Plant Sterols And Stanols
Plant sterols are natural substances found in small quantities in many fruits, vegetables, nuts, seeds, cereals, legumes, vegetable oils, and other plant sources. Research has demonstrated that taking plant sterols orally significantly reduces total and low-density lipoprotein (LDL) cholesterol levels, but has little or no effect on high-density lipoprotein (HDL) cholesterol levels. LDL is considered to be the “bad cholesterol,” while HDL is considered to be the “good cholesterol.” The way it works is that plant sterols block cholesterol absorption in the intestines, which in turn results in lowered LDL cholesterol in the bloodstream. Plant sterols has been reported to decrease LDL cholesterol levels nine to 20 percent, and usual doses have ranged between 800 mg to six grams per day and given before meals. Plant sterols are typically given in conjunction with a low-fat diet.2,3,4,5,6,7,8,9,10,11 Orally, plant sterols are usually well tolerated. Ezetimibe (Zetia), a medication used to lower cholesterol levels, inhibits intestinal absorption of plant sterols.

Similar to sterols, plant stanols are natural substances that occur in even smaller quantities in many of the same sources. Like sterols, stanols block the absorption of cholesterol in the intestines. Taking plant stanols orally is effective for reducing total and LDL- cholesterol in about 88 percent of adult patients when used alone or in combination with a low-fat diet or statin drug (drug that inhibits the production of cholesterol in the body).12,13,14,15,16,17,18,19,20,21,22,23,24,25,26,27 When used alone it can reduce total and LDL cholesterol levels by 10 to 15 percent. When added to statin drugs, sitostanol reduces total cholesterol and LDL cholesterol by an additional three to 11 percent and seven to 16 percent, respectively. Clinical studies have used from 800 mg to four grams per day.28 Orally, plant stanols seem to be very well tolerated. Plant stanols can reduce absorption and blood levels of beta-carotene, so it should be used at a different time if you are taking beta-carotene supplements.

Inositol Hexanicotinate High amounts (several grams per day) of niacin lower cholesterol; an effect recognized in the approval of niacin as a prescription medication for high cholesterol.29 At such intakes, however, acute symptoms (flushing, headache, stomachache) may be severe. In an attempt to avoid the side effects of niacin, alternative health practitioners increasingly use inositol hexanicotinate (aka, “no-flush niacin”), recommending 500 to 1,000 mg, taken three times per day, instead of niacin.30,31 This special form of niacin has been reported to lower serum cholesterol but so far has not been found to cause significant toxicity.32

Omega-3 Fatty Acids From Fish Oil Including fish as a regular part of the diet has been shown to increase HDL cholesterol33 and is linked to a reduced risk of heart disease in the majority of studies.34 One reason that it has this effect is its oils contain the omega-3 fatty acids (O3FA) which appear to protect against heart disease.35 When used supplementally, however, there is contradictory evidence about the effects of fish oil on blood fat levels. Some clinical research shows fish oil supplementation can decrease elevated triglyceride levels, and decrease LDL cholesterol and increase levels of HDL cholesterol.36,37,38 However, other clinical research did not show beneficial effects on cholesterol levels.39 Nevertheless, fish oil from supplements or from dietary sources has been shown to reduce triglyceride levels by 20 to 50 percent. This effect appears to be dose-dependent.40,41,42,43 Fish oil preparations providing 465 mg of eicosapentaenoic acid (EPA) and 375 mg of docosahexaenoic acid (DHA) is particularly effective in conjunction with dietary modifications.44

In addition, research suggests that fish oil supplementation may be superior to the cholesterol-reducing drug rosuvastatin (Crestor®) for patients with heart failure. In a study published in The Lancet,45 researchers gave 1,000 mg of omega-3 fatty acids from fish oil to about 3,500 patients with heart failure, while another 3,500 heart failure patients received a placebo. After four years researchers found that those taking the omega-3 fatty acids had a nine percent relative risk reduction of dying, and an eight percent relative risk reduction for being hospitalized. The researchers concluded their study demonstrated that long-term administration of 1,000 mg daily omega-3 fatty acids effectively reduced all-cause mortality and admissions to hospital for cardiovascular reasons.

The same researchers conducted a parallel study, giving rosuvastatin to 2,285 heart failure patients, and placebos to 2,289 heart failure patients. After four years researchers found little difference in heart failure rates between those given omega-3 fatty acids and those given rosuvastatin. In comparing the results, the researchers concluded that the omega-3 fatty acids were slightly more effective than rosuvastatin.46

Dietary Considerations
I would be remiss if I did not briefly recount the incredibly important role that diet plays in cardiovascular health. Specifically, the Mediterranean diet has extensive patient-oriented outcome data showing a significant risk reduction in mortality rates and in rates of fatal and nonfatal heart attack.47 Strong evidence support Mediterranean dietary patterns, including intake of vegetables and nuts, as protective against coronary heath disease.48

The Mediterranean Diet

The Mediterranean diet is based upon the diets of at least 16 countries that border the Mediterranean Sea. Although there are many differences in culture, ethnic background, religion, economy and agricultural production which result in variations in food intake among the population groups, there is still a common Mediterranean dietary pattern which includes:

  • High consumption of fruits, vegetables, bread and other cereals, potatoes, beans, nuts and seeds
  • Olive oil is an important monounsaturated fat source
  • Dairy products, fish and poultry are consumed in low to moderate amounts, and little red meat is eaten
  • Eggs are consumed zero to four times a week
  • Wine is consumed in low to moderate amounts

In addition, there is strong evidence for the protective effect of monounsaturated fatty acids and prudent dietary patterns.49 Research clearly demonstrates that the people at low risk for CVD eat lots of vegetables, fruits, beans, whole grains and fish: a prudent diet.

Those at high risk for CVD eat the typical Western pattern diet loaded with red meat, processed meat, refined grains, sweets and desserts, fried foods and high-fat dairy products.50,51 Furthermore, strong evidence has also shown a clear and harmful relationship between CVD and the intake of trans-fatty acids and foods with a high glycemic index or load.52

In 2006 the American Heart Association released guidelines that integrate recommendations from a variety of diets into a single plan. The emphasis should be on diets that are rich in fruits, vegetables, and healthful fatty acids and that limit saturated fat intake. A stepwise individualized approach may be a practical way to help reduce your cardiovascular disease risk.53 Visit www.americanheart.org for more information.

There are many dietary supplements that may be used as part of your total program for lowering cholesterol and/or otherwise help in reducing risk of cardiovascular disease. Good choices include plant sterols/stanols, inositol hexanicotinate, and omega-3 fatty acids from fish oils. In addition, a healthy dietary program such as the Mediterranean diet should be the first line of defense for reducing the risk of cardiovascular disease.


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Gene Bruno, MS, MHS

Gene Bruno is the Dean of Academics and Professor of Dietary Supplement Science for Huntington College of Health Sciences (a nationally accredited distance learning college offering diplomas and degrees in nutrition and other health science related subjects. Gene has two undergraduate Diplomas in Nutrition, a Bachelor’s in Nutrition, a Master’s in Nutrition, a Graduate Diploma in Herbal Medicine, and a Master’s in Herbal Medicine. As a 32 year veteran of the Dietary Supplement industry, Gene has educated and trained natural product retailers and health care professionals, has researched and formulated natural products for dozens of dietary supplement companies, and has written articles on nutrition, herbal medicine, nutraceuticals and integrative health issues for trade, consumer magazines, and peer-reviewed publications. Gene's latest book, A Guide to Complimentary Treatments for Diabetes, is available on Amazon.com, and other fine retailers.