I do a lot of health checks in my family clinic here at BJU, and a large percentage have problems with their cholesterol tests. Since high cholesterol is one of the major risk factors for heart disease, I focus a lot of my time with them on proper diet. But what is a proper diet, exactly? We hear so many crazy diet tips from so many sources, but what are the proven high-yield foods that people should focus on?
First, most sources agree on the most high-yield foods: nuts; fish; fiber; olive oils; and plant sterols/stanols. How much does each group benefit? Find out in the graph below from the Natural Medicines Comprehensive Database, my perennial favorite website for evidence-based supplement research:
The NMCD has written a great free article on which natural products work to improve cholesterol. As you see below on their Recommendation Chart, their green area of “Likely Safe + Effective/Likely Effective” has quite a few products, including fish oil; barley, beta-glucans, blond psyllium, niacin, oat bran, and plant stanols and sterols:
My personal tips for anyone who has high cholesterol, even if they take medicines, are these:
- Eat more nuts — a few servings a week can help more than you think. Look at the chart above: walnuts can lower total cholesterol by 8-16%
- Eat fatty fish (salmon or sardines) at least twice a week, more if you can get it. Fish oil can lower triglycerides an amazing 20-50%, and most likely has overall benefit to your heart. I’m a big fan of fish oil for everyone in the family.
- Fiber, fiber, fiber! Fiber can lower total cholesterol 5-26%. Fiber is especially important for breakfast: even the fiber from Cheerios can help, but oatmeal, muesli, or dark breads also are a better source. And don’t forget that fruits and vegetables also have a lot of fiber.
- Improve your breakfast. The worst offenders usually have a very American breakfast of eggs and meat. A far healthier choice would be some fiber (dark bread, muesli, oatmeal) with a cup of yogurt and fruit. Want some sugar? Pour honey into non-sweetened yogurt. Did you know a yogurt a day also helps keep your weight down?
- Think brown over white. If you must eat your pasta, rice and breads, at least try to switch from lily-white versions to the darker ones. Pick any, I don’t care — all brown grains have more fiber and nutrients than the ultra-processed white grains. This also has the added benefit of decreasing your risk of getting diabetes.
- Switch to olive oil. We all need some fat in our diet, but there are good fats and bad fats, and it’s hard to beat olive oil for better health.
- Avoid trans-fats. Trans-fat definitely tops the list of bad fats. This issue fortunately has received a lot of media exposure, but many cookies and snacks still contain a lot of this unnatural and artery-clogging fat. Take a look at your labels, which now require details about trans fats.
I’m in America right now, visiting my family for the first time in over a year. I’ve been having a wonderful time with them – right up until my older brother casually told me how, a year ago, his cholesterol was checked for the first time and “something was high, like I think my triglycerides were over 800, and my good cholesterol was low, and my total was over 300. Something like that…”
Well, that certainly perked up my ears. My oldest brother had cholesterol problems at such dangerously high levels (normal TG is under 150) that he was a “walking heart attack risk” before the age of 50. Needless to say, I picked up my jaw off the floor and had a long brother/doctor heart-to-heart discussion with him about how serious this was. I even showed him his cardiovascular risk score (from myhealthcheckup.com) and showed him how he has a 12% risk of having a heart attack or a stroke in the next 10 years (normal risk is ~5%; mine is 1.5%; anything over 10% worries us docs). I’m not exactly sure how that doctor last year let him get out of his office without medicines or strong warnings, but it doesn’t really matter now; I have no intention of letting my only older brother depart from this world prematurely.
One important point for my readers is that for many of you, as well as for my brother, lifestyle changes only take you so far. Honestly, even if my brother spent 3-6 months losing 10 kilograms and having a hardcore low-fat diet, his levels still would be higher than normal, certainly still high enough to be laying down that artery-clogging cholesterol plaque in his heart and brain. Many people cling to this noble idea that lifestyle changes will help a lot, and they absolutely do and should be a part of anyone’s treatment, including when on prescription meds. But for a great many of us, medicines are inevitable. That’s not a bad thing at all! It’s just the hard draw of our genetic makeup. This idea is called epigenetics, a very trendy and exciting research term: our genetic makeup determines a lot about which diseases we get, but our environment can dramatically effect how severe, or how quickly, we develop those pre-programmed diseases. In my brother’s case, he likely has a genetic weakness for cholesterol, especially triglycerides, but his decades of a typical American diet clearly makes his condition worse than it could be.
That’s why cholesterol-lowering medicines for many of us are not only inevitable but essential. The prescription statins such as Lipitor have been remarkably effective for tens of millions of people, and they literally can cut your risk of heart attacks and strokes more than 50%. But another take-home message is that a few natural medicines can also really help many of us. The best evidence is for omega-3 fatty acids as well as niacin, but fiber and other natural products also help a bit.
I’ve written a lot about omega-3, a natural fatty acid which is found in all the fatty fish, especially salmon, mackerel and sardines. The healthiest way to get this is to eat those fish as often as possible, at least twice a week. If that’s not too practical, all pharmacies carry fish oil supplements.
If you do decide to take it, and if you can tolerate the fishy aftertaste, there are some key facts:
- LOOK CLOSELY AT THE FINE PRINT. Sure, it may say “1000mg fish oil”, but we’re not interested in that. We want to know the TOTAL AMOUNT OF OMEGA 3 (DHA and EPA) – which is usually only a third of the total oil amount! So the key is to look at the nutrition label to see how much TOTAL omega 3 it has — again a combination of DHA and EPA. Usually, your 1,000mg of fish oil only has about 360mg of omega-3. That means, if you need to take 1 gram a day of omega 3, you need to take 3 capsules. (Shoppers tip: in the US, the megastores Costco and Sam’s Club have big bottles of higher-strength, and enteric-coated, softgel capsules. I always stock up at Costco when I go home).
- For general low cholesterol issues, people should usually take 1 gram a day of the omega 3.
- For more severe cholesterol problems (such as my brother), usually 2-3 grams a day of omega 3 is recommended. That means some of you may need to take ~8 pills a day, if you can tolerate them.
- Don’t forget that omega-3 is mostly beneficial for triglycerides; it can lower TGs by 23-45%. It is NOT very effective for lowering total cholesterol, and it actually raises LDL a bit, which may surprise many of you. But it also raises HDL, the “good cholesterol”, by a similar amount – thus canceling out the bad effect on LDL (we think). To be most effective in my brother’s case, he would need to take a lot, at least 2 grams – but 4 grams is even better, if he can tolerate it.
Another natural treatment for cholesterol, niacin, is actually a simple over-the-counter mineral which is quite cheap. Niacin is quite effective for some types of high cholesterol but isn’t commonly used – mostly due to the side effects and liver problems. Here are some important points:
- Niacin is great for lowering triglycerides, at high doses >1,500mg daily. It lowers triglycerides by 20% to 50%.
- Niacin decreases LDL-C by about 5% to 25%.
- It’s excellent for increasing HDL-C. It increases HDL-C by up to 35%.
But side effects of niacin are very common, and many people cannot tolerate this for too long. The most common problem is headaches and a flushing reaction people get after taking their medicines, almost like a hot flash. This can range from barely noticeable to intolerable. Some tricks to avoid the side effects are to take a baby aspirin 1/2 hour before your niacin, and also to buy the extended-release and not the immediate-release niacin. The most concerning — but rarer — side effect is liver toxicity; you should not start niacin by yourself without first getting your liver function tested by your doctor. And your doctor can help you choose which niacin is best. The extended-release pills have less flushing and headache effects but they also increase the risk of liver toxicity.
Niacin can also increase glucose levels, so diabetic or pre-diabetic persons should discuss this issue with their doctor before starting niacin.
One great thing about niacin is price – the OTC versions can be as cheap at $10 a month. But then you also cannot guarantee that the doses are totally accurate; in some cases, it’s still better to get the prescription versions. If you have insurance, it’s probably best to get it from your doctor, or at least get their recommendation as to which, if any niacin, you should take.
As for prescription medicine, my brother’s triglycerides are best treated with prescription fenofibrate, usually called Tricor in most countries. This medicine has a long track record and is, by far, the top choice that doctors would use in this case – much more than niacin, for example. Fenofibrate lowers TGs over 50%, and it also lowers LDL and raises HDL. Thus, it’s a potent triple-benefit for people with seriously high triglycerides. But since he’s currently waiting for his health insurance to kick in (welcome to America!), there’s nothing at all wrong with now starting omega-3 supplements right now, and perhaps niacin if he gets his liver tests first. There’s also a bunch of fiber supplements and others that work a bit: here’s a nice graph from the Natural Medicines Database article on natural ways to lower cholesterol:
So I’m now heading back to China, at least feeling a bit better that I could help my brother out. The hardest part – lifestyle changes and weight loss – will be up to him.
Last year I wrote about how red yeast rice can be an effective natural supplement to lower cholesterol; this is only natural since the rice’s active ingredient is lovastatin, which is one of the official prescription medicines to lower cholesterol. But I just read a disturbing new review by my favorite vitamin-monitoring group, Consumerlab. This independent lab has yet again done an outstanding service by analyzing a dozen of the most popular red yeast rice brands; their major findings show:
- Most of the pills had very little of the active ingredient, lovastatin (and monacolins)
- The range of lovastatin amounts between brands was enormous, and none of the labels specifically say how much of the active ingredient is in there (which they can never state, since they are technically herbal supplements and are forbidden by the FDA to make any health claims)
- Many brands had even less of the active ingredient than they did in previous tests
- A few were contaminated with a mycotoxin called citrinin, which may be associated with kidney disease (but not proven).
I think such information is unfortunate but essential to make the supplement industry more trustworthy and accountable. I am now a lot less enthusiastic about recommending red yeast rice as a “healthy alternative” to the prescription medicines. Why waste your money on this supplement if there’s only a tiny amount of the active ingredient — and if it may be contaminated? Why take the risk when the prescription versions have overwhelming evidence of effectiveness — and don’t have toxic contaminants?
Also, there are many Chinese medicines with red yeast rice, and I had previously liked the more official Xue Zhi Kang brand; but I now would certainly like to see similar independent tests of this brand and other Chinese versions before recommending. Maybe they already exist; does anyone know of a Chinese article reviewing this issue?
How many of you are like myself and take fish oil or flax oil supplements? This is one of the world’s most popular supplements, as many have heard about the health benefits of the main ingredient, omega-3 fatty acid (DHA and EPA). But just how effective is omega-3, and for what diseases? Let’s look at the best evidence — there’s a lot to review.
First, the National Center for Complementary and Alternative Medicine has a nice review of Omega-3 that readers should check out. Here’s their piece on the research:
Status of Research on Omega-3s:
Epidemiological studies done more than 30 years ago noted relatively low death rates due to cardiovascular disease in Eskimo populations with high fish consumption. Since these early studies, numerous observational and clinical trials have studied fish oil and omega-3 fatty acids for a wide variety of diseases and conditions. Overall, the evidence appears the most promising for improving cardiovascular disease risk factors. For example, studies show that increasing levels of DHA and EPA—either by eating fish or taking fish oil supplements—lowers triglycerides, slightly lowers blood pressure, may slow the progression of atherosclerosis (hardening of arteries), and may reduce the risk of heart attack, stroke, and death among people with cardiovascular disease.
Several small studies have also found that fish oil may benefit people who have rheumatoid arthritis (RA). High doses of fish oil significantly reduced RA patients’ morning stiffness, number of swollen joints, and need for corticosteroid drugs.
Additionally, omega-3s have been studied for conditions such as asthma, dementia, diabetes, inflammatory bowel disease, lupus, osteoporosis, and renal disease, as well as organ transplantation outcomes (e.g., decreasing the likelihood of rejection). However, more research is needed before conclusions can be drawn about these conditions.
The always-useful Prescriber’s Letter has a nice patient handout on omega-3 (Detail-Document on Omega 3: Prescriber’s Letter). Here are some highlights:
What are omega-3 fatty acids?
Omega-3 fatty acids include eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA), found in fish, and alpha-linolenic acid, found in soy, canola oil, flaxseed, and English walnuts.
For what conditions are omega-3 fatty acids effective?
There is good evidence that omega-3 fatty acids, particularly EPA and DHA, prevent heart disease. In people who already have heart disease, they help prevent death, heart attack, and stroke. They also reduce triglycerides. Omega-3 fatty acids might also help rheumatoid arthritis, high blood pressure, depression, bipolar disorder, menstrual pain, and certain kidney problems.
What is the best source of omega-3 fatty acids?
The best source of omega-3 fatty acids is fatty fish, like salmon. The American Heart Association (AHA) recommends that everyone eat at least two fatty fish meals (baked or broiled) weekly for cardiovascular health. People who have heart disease should try to eat fatty fish daily. Also add foods rich in alpha-linolenic acid (canola oil, soy, English walnuts, flaxseed) to your diet. But they are not good substitutes for fish because they do not provide enough EPA/DHA. Fish oil capsules are a convenient way to get your omega-3 fatty acids, especially if you need high doses. Fish oil capsules are sold over-the-counter or by prescription (Lovaza [formerly Omacor] in U.S.). Ask your healthcare provider if fish oil capsules are right for you.
Should I be concerned about mercury in fish?
Women who are pregnant or may become pregnant or are breastfeeding, and young children are at risk of mercury toxicity from certain fish. The EPA (U.S.) and Health Canada have specific recommendations for which fish these at-risk persons should avoid or limit. Fish low in mercury include shrimp, canned light tuna (not albacore), salmon, pollock, and catfish. Fish oil capsules are generally low in mercury and other pollutants. For more information, see http://www.epa.gov/waterscience/fishadvice/advice.html (U.S.) http://www.hc-sc.gc.ca/fn-an/securit/chem-chim/environ/mercur/cons-adv-etud-eng.php. (Canada).
How do I choose a fish oil product?
Over-the-counter fish oil is considered a supplement, not a drug, so quality and content varies. Choose products with the “USP Verified Mark” on the label. These have been tested, and have acceptable levels of mercury, other heavy metals, PCBs, and dioxins. They are confirmed to contain what the label says they contain. The omega-3 content is the labeled amount of DHA plus EPA.
Other data from Prescriber’s Letter:
Low Cholesterol: “Omega-3 has a lot of good data that it lowers cholesterol. Clinical research shows that taking fish oil in doses of up to 1-5 grams/day can reduce triglycerides by as much as 20% to 50%. But keep in mind that it is NOT effective for lowering total cholesterol or LDL-C. In fact, some people have a slight increase in LDL-C while taking fish oil. But they also tend to have a slight increase in HDL-C. Overall, the benefit outweighs the risk.”
High Blood Pressure: “there is relatively little evidence available on the use of fish oil specifically for hypertension.”
Heart Disease: “There is good evidence that routinely eating fatty fish, such as salmon, can reduce the risk of heart disease and all-cause mortality.”
My Bottom Line
I think there’s strong evidence that omega-3 helps lower heart disease risk and overall mortality, even in healthy groups such as myself, which is why I take it. Side effects in the stomach are usually minimal. However, the medical community is not in unison regarding omega-3 as a wonder-pill, at least in terms of supplements. Most people should be able to get enough omega-3 simply from eating a lot of fatty fish (salmon, mackerel, sardines), at least twice a week. This should be everyone’s first choice; those of you who hate fish, or are worried about mercury and other contaminations in your fish, should be the ones to consider a supplement.
As for which supplement to buy, be very careful about not getting a cheap supplement which may be contaminated with mercury or simply may not have enough omega-3. Stick to top brands, or try to stock up at home each year.
And just as importantly for those who take supplements: make sure your total daily intake of omega-3 DHA and EPA is at least 1 gram a day. Bottles may say something misleadingly impressive like “one gram of fish oil per pill”, but the crucial ingredient is on the back label: the total amount of omega 3 (DHA + EPA) is the key! So, if your pill has 500mg total DHA and EPA, then you’d take it twice a day.
One more thing: stick to fish oil and not flax oil. Flax oil doesn’t have enough of the DHA and EPA, which are much more potent than the omega-3 ALA that predominates in flax oil.
Those of you with high cholesterol will be happy to learn that there are some legitimate options to your statin pills. Many people cannot tolerate the extremely popular statin pills, especially from side effects of muscle aches. But there’s now some very strong evidence that herbal medicines, including red yeast rice, can be at least as effective as a statin, and without the side effects. Too good to be true? Maybe not…
Red yeast rice is a bright reddish purple fermented rice, which acquires its colour from being cultivated with the mold Monascus purpureus. Red yeast rice is known as Zhi Tai when in powdered form but is called Xue Zhi Kang in alcohol extract form. This has been used in China for many centuries for many reasons, but researchers have been very interested in its effectiveness in lowering cholesterol and preventing heart disease (similar benefits from statins). It seems that the main active ingredient is indeed the natural form of a common statin, lovastatin — but researchers feel that other ingredients inside may add more protective effects. There is an official patented Chinese TCM formulation, called Xue Zhi Kang (xue2 zhi1 kang2 jiao nang 血脂康 胶囊), which has the equivalent of 10mg of lovastatin. The ScienceDaily website has a nice 2008 review of a well-designed study, printed in American Journal of Cardiology, which followed 5,000 persons after their first heart attack, and divided them into two groups taking either xuezhikang or placebo. After 5 years:
Frequencies of the primary end point were 10.4% in the placebo group and 5.7% in the XZK-treated group, with absolute and relative decreases of 4.7% and 45%, respectively. Treatment with XZK also significantly decreased CV and total mortality by 30% and 33%, the need for coronary revascularization by 1/3, and lowered total and low-density lipoprotein cholesterol and triglycerides, but raised high-density lipoprotein cholesterol levels. In conclusion, long-term therapy with XZK significantly decreased the recurrence of coronary events and the occurrence of new CV events and deaths, improved lipoprotein regulation, and was safe and well tolerated.
This is impressive data, and the study design is very well done, which means the evidence is quite strong. One co-author, Dr Capuzzi, has a nice summary:
“It’s very exciting because this is a natural product and had very few adverse side effects including no abnormal blood changes,” said Capuzzi. “People in the Far East have been taking Chinese red yeast rice as food for thousands of years, but no one has ever studied it clinically in a double-blind manner with a purified product against a placebo group until now and we are pleased with the results. However, people in the United States should know that the commercially available over-the-counter supplement found in your average health food store is not what was studied here. Those over-the-counter supplements are not regulated, so exact amounts of active ingredient are unknown and their efficacy has not been studied yet.”
In another randomized trial study, printed last year in the Annals of Internal Medicine, patients who had previously failed treatment of statins due to side effects were given 1800mg of red yeast rice twice a day versus placebo. The red yeast rice group had a significant improvement in cholesterol numbers — with no major reports of severe muscle aches they previously had on the statins.
There are other studies that also show similar benefits. In fact, the evidence is so strong that it is classified as Grade A evidence: “Strong scientific evidence for use”. This is the highest grade that any therapy can get. There are a number of good reviews of red yeast rice in Western literature, including from Medscape; the Mayo Clinic; WebMD; MedlinePlus; and NCCAM. There’s also more informal information from the TCM blog Qi Spot. You can find more scholarly information in the 2008 review from Chinese Medical Journal.
The Bottom Line
I’m impressed enough by all this to start stocking it in my clinic’s pharmacy, and I will start to discuss this option with patients as well. The evidence for this herbal medicine is unusually strong, and this could become one of China’s more popular medicines around the world, as it seems to have similar cholesterol reducing properties as the statins — without those liver and muscle side effects. Please note that people already on statins and very happy with them should not add this medicine, as the active ingredient is about the same. But for those who couldn’t tolerate the statin side effects, or even those newly diagnosed with just slightly elevated cholesterol who want to avoid “prescription” medicines, you may want to consider discussing red yeast rice with your doctor.
But it’s also important to buy the proper Chinese version of xuezhikang, since there are reports of pills being doctored with actual statin medicines. The photo above shows the official patented Chinese version. There seem to be other patents in other countries, including Lipascor. In America, the pills Cholestin are pure red yeast rice.
What Else Works For Cholesterol?
There’s a nice summary of herbal medicines, including red yeast rice, from Natural Medicines Database. There’s also pretty good evidence for the omega-3 in fish oil; at least 1 gram a day of the supplement may help, independently of statin’s benefits. And the mineral niacin can also be extremely effective for certain people, although the flushing side effects can be severe when using the immediate release tablet, and dosing is tricky.