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.40,41,42,43Fish 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.
Conclusion
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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