How to chop down sky-high cholesterol

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A powerful no-drug strategy for people with cholesterol levels of 300-plus

You have some routine blood tests done. Days later, your doctor gives you a call to report that everything's just fine--- except your blood cholesterol. The level is 330 milligrams per deciliter of blood (mg/dl), which far exceeds the upper limit of 200 mg/dl recommended by the National Cholesterol Education Program and the American Heart Association. Your risk of heart disease may have just hit the stratosphere.

So what's to be done?

"The knee-jerk reaction of most doctors in this country would be to put you on cholesterol-lowering drugs," says William P. Castelli, M.D., Prevention advisor and director of the on-going Framingham Heart Study in Massachusetts. "There's no question that special steps are in order for people with cholesterol above 300 mg/dl. But before you spend money on medication, I say you should talk to your doctor about investing a good six months in a solid cholesterol-lowering diet and exercise program."

Other experts agree. They say that people with sky-high blood cholesterol can make lifestyle changes that, in some cases, can preclude the need for cholesterol-lowering drugs. People who already have heart disease---that is, they've had a heart attack, a blockage documented by an angiogram, a bypass operation, an angioplasty or they're on drugs for angina---might not be able to wait six months. They may need to turn to cholesterol-lowering medications sooner. But most others are good candidates for the nondrug plan we present here: Prevention's Cholesterol Attack Plan.

It's worth serious consideration because experts say that any cholesterol reading above 240 mg/dl may place you at high risk of having coronary heart disease (CHD). (A 240- plus cholesterol reading by itself does not definitely put you at high risk but is a warning sign. As we'll see shortly, other factors play a role, too.) CHD is the condition in which major blood vessels leading to the heart are narrowed with cholesterol-containing blockages, called plaque. If a blood vessel becomes completely plugged up, the end result is a heart attack.

Occasionally, people with cholesterol above 300 mg/dl get it up there by "sheer gluttony," in Dr. Castelli's words---"by pigging out on foods like steaks for breakfast, lunch and supper."

But that's not the typical case. Usually sky-high blood cholesterol is the result of a genetic disorder called familial hypercholesterolemia. The higher your cholesterol is, the more likely it is that the problem is of genetic origin.

"Whether your cholesterol is high because of the way you eat or because you have the worst genes in the world," Dr. Castelli says, "you'll have to follow a diet low in total fat, saturated fat and cholesterol, and get more exercise--- whether or not you go on medication. Some people who try the nondrug approach first will be cured by diet alone; others won't be, but will be better prepared to go on cholesterol-lowering drugs." By being "better prepared" he means you'll need a lower dose of medication---and that decreases the potential side effects of the drug, as well as saving money.

So if you're a candidate for the nondrug strategy, with your doctor's guidance you can give our Cholesterol Attack Plan a try for six months. (Don't attempt this program without letting your doctor know, and be sure to continue with any medications you're currently taking.) It's a multiphased assault on the problem. The more pieces of the package you take on, the more likely you are to chop down your cholesterol reading, possibly with little or no medication. "A successful cholesterol-lowering program is making a lot of little decisions all day long," Dr. Castelli says. "It's like saving all of your pennies in a bank account."

STEP 1: VERIFY THE PROBLEM
Make sure your initial sky-high cholesterol reading is correct. Ask your physician to order a repeat blood test (hypodermically drawn) from a reputable laboratory---one that's certified by the Centers for Disease Control for testing blood lipids. You don't need to fast before tests for total blood cholesterol. (Beware of finger-stick tests done with portable cholesterol analyzers. The results are not very precise, though such tests are sometimes used in initial screenings as adjuncts to further testing.)

If the second measurement--- which should be made one to eight weeks after the first---is within 30 points of the first, then take the average of the two tests as your cholesterol level. But if the discrepancy is greater than 30 points, a third test should be done within one to eight weeks, and the average of the three tests should be used as your cholesterol level.

If you still come out in the risky zone (240 mg/dl or higher), you should have further testing, called lipoprotein analysis. For this test, you shouldn't have anything to eat for 10 to 12 hours beforehand. Lipoprotein analysis reveals how much of your total cholesterol is the "good" kind (HDL), how much is the "bad" kind (LDL) and how high your triglycerides are. (If a family member has had a heart attack or stroke before age 40, you should have your blood checked for high LDLs or triglycerides, even if your total cholesterol is under 240.)

If your LDL cholesterol turns out to be 160 mg/dl or higher, or your triglycerides are 150 mg/dl or higher, or both, then you're at high risk for heart disease. The LDL cutoff is even lower---130 mg/dl---for someone who already has heart disease or who has two other risk factors for CHD. Risk factors include cigarette smoking, high blood pressure, being a male (since before middle age, men are much more likely than women to have heart disease), diabetes, HDL cholesterol below 35 mg/dl, or family history of premature heart disease (that is, a heart attack or sudden death before age 55 in a parent or sibling).

On the other hand, it's possible---but very unlikely---that a high total-cholesterol reading (even one as high as 300 mg/dl) is the result of having high levels of "good" HDL and safe levels of "bad" LDL and triglycerides. According to Dr. Castelli, there are certain people with HDLs of 80 to 100 who---despite high total-cholesterol levels---are protected against heart disease. (Have a repeat HDL test if it comes out this high, to make sure it's not a fluke.) If the ratio of total cholesterol to HDL cholesterol is less than 3.5, he thinks there's little worry about heart disease and that you need only to avoid very fatty foods. In most cases, however, having high blood cholesterol is the result of having high levels of LDL.

Be aware, too, that certain diseases---of the thyroid gland, liver or kidney, for instance---can raise blood cholesterol, as can some medications, such as certain diuretics. Your physician needs to make sure your cholesterol is not related to one of these before starting you on an aggressive diet or medication.

STEP 2: MAKE SOME POSITIVE CHANGES
It's confirmed: You've had all the right tests, and your cholesterol level is still above 300 mg/dl with an LDL level well over 160 mg/dl. Next, devote two months to three smart moves known to cut cholesterol down to size.

Attack the fat. The single most effective step you can take to lower your blood cholesterol is to cut the amount of saturated fat you consume to less than 7 percent of your calorie intake, down from the American average of 13 percent.

One way is to drop your total fat intake to 20 percent of total calories, which automatically cuts your saturated fat intake way down. People whose cholesterol is sky-high because they've been eating tons of saturated fat may respond to the guideline for the general public to lower fat to 30 percent of calorie intake. But most people with cholesterol above 300 need to cut fat further. Here's how to shoot for the 20 percent mark:

Have no more than one serving of lean meat, fish or poultry a day, limiting portion size to 3 or 4 ounces (the size of a deck of cards).
Limit red meat to two or three servings a week.
Have two servings of whole grains, breads or starches (like pasta and potatoes) with every meal--- more if you can afford the calories.
Have one vegetarian meal each day. (Combine pasta, rice, barley and starchy vegetables, such as potatoes, corn and winter squash.)
Each day, substitute two servings of nonfat milk products (such as skim milk and nonfat yogurt) for two servings of fattier ones.
Each day, use no more than two to four teaspoons of added fat or oil in cooking or on foods. (When you do, stick with olive oil, canola oil or liquid plant oil, such as corn, sunflower or safflower.) Choose margarine with a liquid vegetable oil listed as the first ingredient. Don't use butter, shortening or lard.
Use only low-fat condiments or toppings---like fat-free butter substitutes, nonfat salad dressings, prepared mustard, horseradish, catsup, chili sauce, relish and salsa.
Note: Dropping your saturated- fat intake automatically lowers cholesterol intake since the two tend to go hand-in-hand in foods. But to stick with the recommended allowance of no more than 200 mg. of cholesterol from foods per day, you should also limit egg yolks (which are rich in cholesterol) to no more than one a week. Cholesterol-free egg substitutes or two egg whites can be substituted for one whole egg in recipes.

You should also avoid organ meats like liver because of their high cholesterol content.

Boost your fiber intake. Include between 20 and 35 grams of dietary fiber in your diet each day, using as much soluble fiber as possible. Prevention advisor James W. Anderson, M.D., of the University of Kentucky College of Medicine, and others have repeatedly demonstrated that eating high amounts of soluble fiber from sources like oat bran, legumes and psyllium can help lower blood cholesterol. You just have to remember to increase your fiber intake gradually and drink plenty of water.

Eat a bowl of high-fiber cereal daily, preferably one with oat bran or psyllium. (Some research suggests that rice bran may have similar cholesterol-lowering effects.)
Slowly work up to having one-half to one cup of legumes a day, such as kidney beans, chick-peas, lima beans, lentils, navy beans or pinto beans. A cup of most types provides about 10 g. of fiber. (You can combine legumes with small amounts of meat, chicken or fish, or mix them with low-fat cheese, rice or pasta, or add them to hearty salads, soups, casseroles, stir-fries with vegetables, or pita-bread sandwiches with sprouts and low-fat cottage cheese.)
Add oat bran to foods whenever you can. One-third cup of oat bran provides about 4 g. of fiber. (Dr. Anderson suggests using oat bran in low-fat muffin recipes, as a meat-loaf extender, in soups and stews as a thickener, as an ingredient in blender shakes, baked into breads and rolls, in place of bread crumbs, in pancake batter and in casseroles.)
Consider taking a multivitamin/ mineral supplement containing iron and zinc, since high amounts of fiber can interfere with the absorption of these and other nutrients.
For more ideas on boosting your fiber intake, see "Nutritional Medicine" in our November 1990 issue.

Get aerobic. Work up to two miles of brisk walking a day. Not only can regular aerobic exercise like walking help lower total cholesterol, LDL cholesterol and blood pressure, but it's also one of the few things you can do to raise your HDL cholesterol. Walking is probably the safest aerobic exercise you can participate in.

Exercise can help you lose weight, as well, which in and of itself can help lower total and LDL cholesterol. (Be aware, however, that even skinny people can have sky-high blood cholesterol.)

STEP THREE: RECHECK
After two months of following Step Two, have your total cholesterol, LDL, triglycerides and HDL levels rechecked. If your LDL cholesterol is below 160 mg/dl (or 130 mg/dl if you have CHD or at least two other risk factors), and your triglycerides are below 150 mg/dl, and your ratio of total cholesterol to HDL is under 4.5, then you've found a diet and exercise solution to your problem. Your risk is now normal. Dr. Castelli maintains that as long as your LDLs and triglycerides are this low, and you have enough HDLs, it's O.K. if your total cholesterol doesn't come all the way down to 200 mg/dl. Keep up the good work. But remember, the lifestyle changes have to be forever or your cholesterol is going to soar again.

"One way to stay on the straight and narrow," says Dr. Castelli, "is to have your blood tested for total cholesterol, LDLs, triglycerides and HDLs regularly for the rest of your life. I recommend testing every three to four months for the first three to four years, then every six months thereafter."

If your LDL cholesterol still isn't below 160, move on to Step Four.

STEP FOUR: TRY PSYLLIUM
One way to try to nudge your LDL cholesterol down further is to give your soluble fiber intake another boost---by adding an over-the- counter psyllium supplement to your Step Two diet.

Dr. Castelli's advice is to take a tablespoon of psyllium each day for a month, then have your blood fats checked. (A tablespoon of sugar- free psyllium adds about 10 g. dietary fiber to your diet.) If the level is still not low enough, take two tablespoons a day for a month and have your blood fats checked. (The slow increase allows you to adapt to psyllium's laxative effects. Drink plenty of water. Do not exceed two tablespoons.)

Note: Some people are allergic to psyllium. Stop taking it if you get allergic symptoms: wheezing, itching or shortness of breath.

If your LDL, triglycerides and total cholesterol-to-HDL ratio are where they should be, then you have found the program that works for you. Keep it up and have regular blood tests. If your LDL cholesterol and triglycerides are still not low enough---and you really want to do everything in your power to lower blood fats without medication---go on to Step Five.

STEP FIVE: GO VEGETARIAN
For two months, go on a strict vegetarian diet with about 10 percent fat calories, such as the heart- disease-reversal diet of Dean Ornish, M.D., described in Prevention's May 1990 issue. His research suggests that such a diet, coupled with exercise and stress-reduction techniques (plus quitting if you smoke), may significantly reverse coronary blockages in just one year. And other research shows that this kind of very-low-fat diet is associated with very low LDLs, triglycerides and total cholesterol.

Although it's tough to follow a diet like this, Dr. Ornish thinks it's important that people know it's a possible alternative to drug therapy for high blood cholesterol. If you want to consider it seriously, it's important that you check with your doctor first. More details on the diet are available in Dr. Dean Ornish's Program for Reversing Heart Disease (Random House, 1990).

In this diet, you continue with all the changes of Step Two but limit fat more, increase carbohydrates and maintain your level of fiber.

Delete all meat, poultry and fish. Let every meal feature foods containing grains and grain products (preferably whole grains), such as bread, cereal, rice, pasta and tortillas; fresh or dried fruits; vegetables and greens; beans; sprouts; and egg whites. Tofu and tempeh, which are naturally high in fat, are permitted in moderation.
Limit milk products to one cup of skim milk or nonfat yogurt a day. Eat no cheese.
Use no oil or egg yolks and only a moderate amount of sugar and salt. Eat no butter, margarine, shortening or lard.
Limit "taste enhancers" to seasonings like herbs, mustard or salsa.
Take a multiple vitamin-and-mineral supplement to ensure you're not missing any nutrients because of the dietary restrictions.
STEP SIX: CHECK YOUR LDL AGAIN
Is it still too high? Don't feel bad. The truth is that many people with familial hypercholesterolemia do wind up needing medication. But at least now you know you've done everything possible to avoid reliance on drugs. And it's possible that after six months of trying, you may need far less medication than you would have otherwise.

"Once you're on cholesterol- lowering drugs," says Dr. Castelli, "it's forever. Therefore, since all of the drugs have side effects, we want you to be on the smallest amount of drug that will be effective." That's why it's still important to stick closely to the Cholesterol Attack Plan while you're on medication.

If your LDLs and triglycerides are now down where they should be, congratulations. (You can now try to reduce the amount of psyllium you're taking.) Your reward for all your lifestyle changes is a healthier heart and longer life.

HOW TO MAKE THE BIG CHANGES
No one is saying that it's easy to dramatically alter your lifestyle to change your blood fats. But plenty of people have done it--- and lowered their cholesterol 100 points. To successfully make such big changes and stick with them, the experts we consulted say . . .

Set measurable goals for yourself. Like getting a certain amount of exercise or a set amount of fiber each day. People who do this feel good about their accomplishments, so they want to do more.

Don't dwell on the negative. Instead of focusing on what you can't have, think about all the things you can have. For instance, instead of lamenting the fact that you can't eat bacon and eggs, think about having whole- wheat pancakes or French toast (made with egg whites in a nonstick pan), topped with jam, powdered sugar or maple syrup . . . or a bagel topped with low- fat cottage cheese and herbs, yogurt cheese, or jelly.

Think about how much more you get to eat on a low-fat, high-carbohydrate diet. Food intake isn't limited on such diets, so many people say that the menus rarely leave them hungry.

Do it because you'll feel good, not out of fear. Prevention advisor Dean Ornish, M.D., who has developed an effective lifestyle program for reversing heart disease, says that fear--- like worrying that you'll have a heart attack---motivates you only for a short time. He emphasizes that people who make the kinds of changes we're talking about stay motivated because they feel so much better.

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