IMPROVING CHOLESTEROL PROFILE WITHOUT DRUGS

YANN A. MEUNIER, MD

Director
Stanford Health Promotion Network
PERSPECTIVE

1. Know your current behavior

2. Assess readiness for change
3. Gather knowledge
4. Build a support network
5. Make a commitment
6. Set an appropriate long term goal
7. Set appropriate short term goals
8. Anticipate/deal with obstacles
9. Manage stress
10. Self-monitor
11. Keep motivated
12. Deal with ambivalence
13. Cultivate a positive inner voice
14. Be a mentor/opinion leader
15. Re-evaluate plan
MORTALITY RELATED TO HIGH CHOLESTEROL (CDC)

 #1 cause of death: Cardio-vascular diseases

 # 3 cause of death: Cerebro-vascular diseases

 #1 + #3 = ~ 40% of all deaths

(+ higher risk for Alzheimer & chronic liver disease)

ROLES OF CHOLESTEROL

 Cell membrane structure

 Human skin barrier (toxins, water loss)

 Precursor of steroid hormones (testosterone,

estrogen, progesterone, cortisone and aldosterone)

 Precursor of bile acids

CHOLESTEROL METABOLISM

 Esterification of dietary cholesterol by

pancreatic exocrine glands

CHOLESTEROL METABOLISM

 Cholesterol penetrates the enterocyte via a

channel (NPC1L1)

 Cholesterol is esterified by a cholesterol acetyl

transferase (ACAT) or pumped back into the
CHOLESTEROL METABOLISM

 Cholesterol absorption can be inhibited by

stanols/sterols

 Stanols/sterols esters lower cholesterol levels by

interfering with micellar absorption

 Inhibition of absorption may be compensated by

increased synthesis
CHOLESTEROL TRANSPORT

 HDL (High Density Lipoprotein)

It brings back cholesterol to the liver

 LDL (Low Density Lipoprotein)

Its over-accumulation and deposition lead to
serious ailments

 VLDL (Very Low Density Lipoprotein)

Converted into LDL by endothelial cell-
associated
lipases
OPTIMAL CHOLESTEROL LEVELS (AHA)

Total Cholesterol

Less than 200 mg/dL

Desirable level that puts you at lower risk for coronary heart
disease

200 to 239 mg/dL

Borderline high

240 mg/dL and above

High blood cholesterol. Twice the risk of CAD as below 200 mg/dl
OPTIMAL CHOLESTEROL LEVELS (AHA)

HDL Cholesterol

Less than 40 mg/dL

Low level. A major risk factor for CAD

40 to 59 mg/dL
The higher the level the better

60 mg/dL and above

High level. Considered protective against CAD
OPTIMAL CHOLESTEROL LEVELS (AHA)

LDL Cholesterol
Less than 100 mg/dL
Optimal
100 to 129 mg/dL
Near or above optimal
 
130 to 159 mg/dL
Borderline high
 
160 to 189 mg/dL
High
 
190 mg/dL and above
Very high
CHOLESTEROL GOALS

Your LDL cholesterol goal depends on how many other

risk factors you have

• No CHD or diabetes and 1 or no risk factor: less than

FACTORS INFLUENCING CHOLESTEROL LEVELS

 Age
 Weight and its body location
 Gender (men, menopause)
 Genetics (enzyme deficiencies, APOE)
 Diseases
 Lifestyle (exercise, stress, smoking)
PHYSIOPATHOLOGICAL CONSEQUENCES OF THE PLAQUE

 Coronary Artery Disease (CAD): angina, MI

 Peripheral Artery Disease (PAD)

 Ischemic Stroke (brain infarct)

 Transient Ischemic Attacks (TIAs)

 Secondary Erectile Disorder (ED)

 Chronic Renal Ischemia ( renal failure)

 CAD RISK FACTORS

 Homocysteine
 C-Reactive Protein (CRP)
 Apolipoprotein B (=LDL), Triglycerides
 Pattern B (low HDL, high T.G., type 2 D.M.)
 Fibrinogen
 Pathologies (diabetes, metabolic syndrome, HTN,
hypothyroidism, uremia, nephrotic syndrome,
anorexia nervosa & depression)
CHOLESTEROL AS CAD RISK FACTOR

 High LDL is responsible for 70% of heart diseases

(leading killer of men and women after 45)
 Age 49-82: The most potent risk factor for CAD
is low HDL (Framingham study)
 Every 2% raise in HDL = 2% in men
and 3% in women decrease in CAD risk
Clinical benefits shown by the VA-HIT study
 Same impact for LDL reduction. Combined benefits
suggested by the HAT study
GENDER AND HEART DISEASE (WOMEN)

Most important risk factors

 Diabetes
 Low HDL
 High triglycerides
 Waist measurement of 35 inches or more
 Inflammatory disorders
Symptoms/disease
 Fatigue, malaise, shortness of breath, nausea, depression
 First heart attack at average age 70 with higher fatality rate than men
 More likely to have microvascular disease
Diagnostic procedures
 ECG stress test less informative than nuclear test
 When angiography shows no discrete lesions: IVUs and pressure flow studies
Treatment
 Less likely to have bypass surgery or angioplasty for coronary lesions
 Longer hospital stays, higher complication rate  
GENDER AND HEART DISEASE (MEN)

Most important risk factors

 High LDL
 High blood pressure in young men
Symptoms/disease
 Unstable angina warrants immediate attention
 First heart attack at average age 65
Diagnostic procedures
 Stress tests more reliable than in women
 Angiography more likely to be informative
Treatment
 More likely to receive bypass surgery, angioplasty for coronary lesions
 Shorter hospital stays
 More likely to enter cardiac rehabilitation  
HDL-C CHD PROTECTION MECHANISMS

 Promotion of peripheral cholesterol transport

 Anti-oxidant / anti-inflammatory action

 Antithrombotic effects
CHOLESTEROL PROFILE IMPROVEMENT STRATEGY

1- DIET

2- EXERCISE

3- SMOKING CESSATION

4- STRESS REDUCTION

5- WEIGHT CONTROL

6- BEHAVIOR CHANGE

7- NUTRITIONAL GENOMICS
 CHOLESTEROL PROFILE IMPROVEMENT STRATEGY

1- DIET

 3 types of fat come from the diet: saturated, mono-unsaturated and

omega-3 omega-6 PUFAs –Poly-Unsaturated Fatty Acids-

 Diets high in omega-3 oils decrease the risk of sudden cardiac death (+ Eskimo
paradox)

 After 1 month a vegetarian diet rich in vegetal sterols, soya proteins and
almonds, the LDL cholesterol decreased 28% (i.e., as much as the group on
statins). It also decreased CRP levels, just like statins (Dr. David Jenkins,
JAMA)

 People with a high level of C-reactive protein (CRP) don’t receive the same
beneficial reductions while on a low-fat, low-cholesterol diet as those with
lower CRP levels
CHOLESTEROL PROFILE IMPROVEMENT STRATEGY

Foods to decrease

Butter, egg yolk (1 a day is OK), sausages (bologna, salami

and corn or hot dogs), organ meats (liver, sweetbreads,
kidney, brain and heart)

Cheese, ice cream, creamy cakes, chocolate

Cookies, granola bars and crackers (rich in hydrogenated oils)

Fatty red meat (prefer lean cuts such as: round, chuck, sirloin
or tenderloin. Buy “choice” or “select” rather than “prime” and
lean or extra lean ground beef). For pork, choose tenderloin or
loin chop. Lean lamb cuts come from the leg, arm and loin.
Trim the outside before cooking.
CHOLESTEROL PROFILE IMPROVEMENT STRATEGY

Duck and goose meat

Saturated oil (like coconut oil, palm oil and palm kernel oil) in:

* Warm food (seriously reduce the intake of hydrogenated

vegetable oils shortenings, margarines and lard)

* Salads (use virgin olive oil, flaxseed oil or colza oil)

CHOLESTEROL PROFILE IMPROVEMENT STRATEGY

Cooking tips

Meats

- Use a rack to drain off fat when you broil, roast or bake

- Don’t baste with drippings, use wine, fruit juice or an acceptable

oil-based-marinade.

- Broil or grill instead of pan-fry

- Cut off all visible fat from meat before cooking and take all the
skin off poultry pieces (if you are roasting a whole chicken or
turkey, remove the skin after cooking)
CHOLESTEROL PROFILE IMPROVEMENT STRATEGY

- Cook a day ahead of time. Stews, boiled meat, soup stock or other
dishes in which fat cooks can be refrigerated. Then, the hardened fat
can be removed from the top.

- Make gravies after the fat has hardened and can be removed from the
liquid

- When a recipe calls for browning the meat first, try browning it under
the broiler instead of in a pan
CHOLESTEROL PROFILE IMPROVEMENT STRATEGY

Vegetables

Add herbs and spices to make vegetables tastier:

- Rosemary with peas, cauliflower and squash

- Oregano with zucchini

- Dill with green beans

- Marjoram with Brussels sprouts, carrots and spinach

- Basil with tomatoes

CHOLESTEROL PROFILE IMPROVEMENT STRATEGY

Oils

Liquid vegetable oils or margarines that contain no more than 2 grams of

saturated fat per tablespoon can be used in many ways in cooking that
require the use of fat, to:

- Brown lean meats and pan or oven-fry fish and poultry

- Saute onions and other vegetables for soup
- Make cream sauces and soups using low fat milk
- Make hot breads, piecrust and cakes
- Pop corn and make cocktail snacks
- Make casseroles using dried peas and beans
- Brown rice and/or for Spanish or curried rice
- Cook dehydrated potatoes and other prepared foods that call for fat
to be added
- Make pancakes or waffles
CHOLESTEROL PROFILE IMPROVEMENT STRATEGY

Foods to increase
1 bowl of oat bran at breakfast with oatmeal. (Note that Psyllium also
decreases total cholesterol)

Fresh vegetables, avocados (rich in good fat), artichokes, lentils and

beans, chick peas (high in isoflavones), rice bran, citrus fruits,
strawberries, apples (rich in pectin) and apple pulp (rich in soluble fiber)

Mulberries, raspberries (rich in resveratrol)

Almonds, pecans, walnuts, hazelnuts, macadamia, pistachios, peanuts.

Almonds can reduce the ratio LDL to HDL up to 12% after 4 weeks
(Journal of the American Heart Association). Eat them natural or “dry
roasted” without added oils or salts. Most of their fat is polyunsaturated
or mono-unsaturated.
CHOLESTEROL PROFILE IMPROVEMENT STRATEGY

Chicken, turkey, lean ham

Fish (sardines, salmon or cod are rich in omega 3). Bake, broil,
grill or boil rather than bread or fry them

Shrimp and crawfish (they have more cholesterol than other types
of fish or seafood but they are lower in total and saturated fat than
most meats and poultry)

Soya (like tofu). Soy is high in isoflavones, which have anti-

oxidant properties (preventing LDL from oxidizing)

Oat or barley bread

Supplements: Red yeast rice, 3x600mg caps, BID, for 6 months =

35 points drop in LDL (Annals of Internal Medicine)
TOTAL PHYTOSTEROL CONTENT
OF SELECTED FOODS

Food Serving Phytosterols (mg)

Wheat germ ½ cup (57 g) 197

Corn oil 1 tablespoon (14 g) 102
Canola oil 1 tablespoon (14 g) 91
Peanuts 1 ounce (28 g) 62
Wheat bran ½ cup (29 g) 58
Almonds 1 ounce (28 g) 34
Brussels sprouts ½ cup (78 g) 34
Rye bread 2 slices (64 g) 33
Macadamia nuts 1 ounce (28 g) 33
Olive oil 1 tablespoon (14 g) 22
HOW DO OMEGA 3 PUFAs PREVENT CHD?

3 main actions:
 Anti-thrombotic (inhibiting VLDL and T.G.
synthesis in the liver)

 Anti-arrythmic

 Anti-inflammatory (forming a different

pattern of prostaglandin)

(American Family Physician, July 1, 2004)

CHOLESTEROL PROFILE IMPROVEMENT STRATEGY

Drinks to decrease
Cow milk

Eggnog
CHOLESTEROL PROFILE IMPROVEMENT STRATEGY

Drinks to increase

Skim milk (fat free), soya milk

Black tea (rich in flavonoids)

Red wine (1 glass for women and 2 glasses for men, at

dinner). If there is no history of alcoholism in the family

Orange or cranberry/cranapple/cranraspberry juice (2 glasses

a day). Vitamin C slows the progression of atherosclerosis
(Journal of the American Heart Association)
PHENOLIC COMPOUND CONCENTRATIONS
IN SEVERAL GRAPE VARIETIES AND WINES

 
Grape / wine Phenolics (mg/L)
 
Thomson seedless 260

Flame seedless 850

Black seedless 920

Cabernet Sauvignon 1800

Syrah 3200
 
THE FRENCH PARADOX

A- Relatively low incidence of CAD

B- Diet rich in saturated fat

 THE FRENCH PARADOX

Incidence of Mortality from Coronary Heart Disease in Different World Regions

Region Plasma Cholesterol (mg/dl) Mortality (per 10,000)

Japan ---- 33
 
France
General 216 102
Toulouse 224 78 (281)
 
USA 209 182
 
UK 240 380
 
 THE FRENCH PARADOX

 Red wine produces flavonoids (quercetin, resveratrol

and ipatechin) after fermentation

 Flavonoids decrease the oxidation of LDL and its

uptake by macrophages

 The alcohol content assures the effective absorption

of flavonoids and tannins
THE FRENCH PARADOX

Opponents’ Arguments

 Social status of drinkers (USA)

 More fruits and vegetables in diet and more
exercise in wine regions (favorable climate)

 
FOODS THAT LOWER LDL CHOLESTEROL

1. Oats
2. Barley and whole grains
3. Beans
4. Eggplant and okra
5. Nuts
6. Vegetable oils (canola, sunflower, safflower)
7. Apples, grapes, strawberries, citrus fruits
8. Soy
9. Fatty fish
10. Fiber supplements
11. Foods with added sterols and stanols (orange juice, chocolate,
etc)
14-PRONG NUTRITION ACTION PLAN

1. Eat meat sparingly

2. Add fish to your diet
3. Eat fruits and vegetables
4. Go for nuts
5. Increase complex carbohydrates and fiber
6. Opt for low-fat dairy products
7. Cut down on saturated fat in cooking
8. Avoid palm and coconut oils
9. Avoid trans fats
10. Reduce dietary cholesterol
11. Reduce salt intake
12. Watch the snacks
13. Drink alcohol only in moderation
14. Read labels carefully
CHOLESTEROL PROFILE IMPROVEMENT STRATEGY

2- EXERCISE
 Exercise increases the HDL and decreases the LDL levels

 It also lowers triglyceride levels and blood pressure, reduces excess

weight, improves heart and lung fitness and diminishes stress

 Guidelines for maximizing the impact of exercise on blood

cholesterol levels
         
Aerobic exercise (jogging, swimming, brisk walking, bicycling, etc)

* As a rule, to be in aerobic conditions one should be able to hold a

conversation without being too winded while exercising

* Moderate intensity + strength training

CHOLESTEROL PROFILE IMPROVEMENT STRATEGY

o Adults are advised to accumulate 150 minutes

of moderate-intensity aerobic activity every week in
addition to strength training. Moderate intensity is
5 or 6 on a 10-point scale of effort (Centers for
Disease Control and Prevention)

o They also are encouraged to wear pedometers to

count the number of steps they take. Moderate intensity
approximates 100 steps a minute
 HOW FIT ARE YOU? (PULSE)

Men Age Unfit Fit Very Fit

20s 86 or more 60-85 59 or less

 
30s 86 or more 64-85 63 or less
 
40s 90 or more 66-89 65 or less
 
50s and older 90 or more 68-89 67 or less
 

Women Age Unfit Fit Very Fit

20s 96 or more 72-95 71 or less

 
30s 98 or more 72-97 71 or less
 
40s 99 or more 74-98 73 or less
 
50s and older 103 or more 76-102 75 or less
CHOLESTEROL PROFILE IMPROVEMENT STRATEGY

3- SMOKING CESSATION
Smoking cessation increases HDL and decreases LDL levels

Points
a- Nicotine is not needed for less than 10 cigarettes per day and
contra-indicated in case of drug interaction, in
pregnant or breast-feeding women and in the adolescent
b- Four As: Ask, Advice, Assist and Arrange
c- Nicotine inhaler or nasal spray is superior to patch
d- Three prong approach: Nicotine (physiological dependence),
Bupropion -Zyban- (aggressiveness, bulimia) and
psychological advice (support, determining the need),
Chantix?
CHOLESTEROL PROFILE IMPROVEMENT STRATEGY

4- STRESS REDUCTION

Stress reduction increases the HDL level.

Meditation, prayer, laughter, yoga, tai chi, Reiki healing,

mindfulness-based stress management, HeartMath, music,
reading, sport (especially martial arts), massage, breathing
techniques, etc
CHOLESTEROL PROFILE IMPROVEMENT STRATEGY

5- WEIGHT CONTROL

Loosing weight increases the HDL level.

Calculate your BMI

Loose weight by decreasing the caloric intake with a

hypocaloric diet and/or increasing output through an
aerobic exercise.
CHOLESTEROL PROFILE IMPROVEMENT STRATEGY

6- BEHAVIOR CHANGE

Keys:

 Self-management of lifestyle choices

 Selecting behaviors you are ready to change
 Setting realistic goals
 Fifteen steps
CHOLESTEROL PROFILE IMPROVEMENT STRATEGY

7- NUTRITIONAL GENOMICS
One size dies not fit all.
The current evidence based on nutrigenetics has begun
to identify subgroups of individuals who benefit more from
different diets.

The continuous progress in nutrigenomics will allow some

time in the future to provide targeted gene-based dietary
advice.
Genotype–Phenotype Associations: Modulation by Diet and Obesity. Jose M. Ordovas Obesity (2008) 16, S40–S46;
doi:10.1038/oby.2008.515
15-STEP BEHAVIOR CHANGE STRATEGY

1. Know your current behavior

2. Assess readiness for change
3. Gather knowledge
4. Build a support network
5. Make a commitment
6. Set an appropriate long term goal
7. Set appropriate short term goals
8. Anticipate/deal with obstacles
9. Manage stress
10. Self-monitor
11. Keep motivated
12. Deal with ambivalence
13. Cultivate a positive inner voice
14. Be a mentor/opinion leader
15. Re-evaluate plan
CHOLESTEROL TESTS

The Mayo Clinic has excellent questionnaires on cholesterol such

as:
 
-  Is your diet hurting your heart?
-  What do your test results mean?
 
They can be taken at the following web site: www.mayoclinic.com

The American Heart Association also has a questionnaire entitled

“test your cholesterol IQ quiz”, which can be found at the
following
web site: www.americanheart.org
TAKEAWAYS

 Approach
 Model
 Processes