Healthy Cholesterol Diet = Low-Fat, Low Cholesterol Diet?

Many people continue to believe that a healthy cholesterol diet means eliminating dietary fat and cholesterol.

For most people, dietary cholesterol intake doesn’t impact blood cholesterol levels and a low-fat diet doesn’t necessarily correlate with improvements in blood cholesterol or cardiovascular health.   In fact, a diet high in refined sugars and high-glycemic carbohydrates appears to have a greater negative impact on blood cholesterol and other markers of cardiovascular health than dietary fat.

A complex combination of genetic and environmental factors interacts to drive the progression of cardiovascular disease.  There is no one healthy cholesterol diet fits all approach when it comes to prevention and management of cardiovascular disease.

Dietary Fat, Carbohydrate and Cardiovascular Disease

The link between saturated fat and cardiovascular disease is highly debated.  Certain types of saturated fatty acids (mostly in dairy and meats) do increase LDL or “bad” cholesterol, but they also increase your HDL or “good” cholesterol.  Certain saturated fatty acids (ie. tropical oils) have a neutral effect on blood cholesterol.  Certain foods that are high in saturated fat (ie. processed meats) are associated with an increased risk for cardiovascular conditions, while others do not appear to pose a clear risk (ie. dairy products). 

Cardiovascular disease risk is reduced when saturated fats are replaced with polyunsaturated fatty acids (vegetable fats), but when replaced with high-glycemic carbohydrates raises triglycerides, decreases HDL cholesterol and LDL particle size.

There is a growing body of evidence that supports the pro-inflammatory effects of saturated fat, however, high intakes of high-glycemic carbohydrates are also pro-inflammatory.   Due to the high blood sugar and insulin response, higher intakes of refined carbohydrates in place of fat is of concern, especially if you are at risk for metabolic syndrome.   Increasing importance of the dyslipidemia and other biologic effects (metabolic syndrome, inflammation, oxidative stress) associated with a high-glycemic load diet are surfacing as they relate to cardiovascular disease and other chronic conditions.

Many studies support the benefits of a Mediterranean dietary pattern on the risk of cardiovascular disease.  Notably, the Mediterranean diet (branded as a healthy cholesterol diet) is low in saturated fat and high-glycemic carbohydrates and high in monounsaturated fats. Consistent evidence indicates that omega-3 fatty acids (EPA and DHA) are effective lipid lowering agents (especially triglycerides and small particle LDL numbers), decrease inflammation and appear beneficial at preventing cardiovascular events.

Dr. Dean Ornish has shown through rigorous study that his diet and lifestyle program (a very low-fat, vegetarian type diet that generally focuses on whole foods along with exercise, stress management and support groups) can slow the progression of, or even reverse, CHD as well as reduce cardiac events in heart disease patients.   His program has been replicated by others and shown to have similar results in volunteers with heart disease as well as those at high risk for CVD, but variability in patient response has been reported.  This variability emphasizes that there is generally no one-size-fits-all diet for CVD (or any other disease) and a personalized diet that takes into account both the science and the individual is best.

Trans fatty acids are consistently associated with a higher risk of heart disease. They are linked with abnormal cholesterol as well as a host of other negative health associations.  A healthy cholesterol diet eliminates all trans fats.


Is LDL Cholesterol the Best Marker for Cardiovascular Disease Risk?

LDL cholesterol is a marker for risk of heart disease, but the bigger question may be your percentage of small, dense LDL particles.  Evidence suggests that a higher percentage of small, dense LDL particles that have been damaged and inflamed by oxidative stress (small particles are at higher risk of oxidation) is a powerful indicator for the development and progression of cardiovascular disease.  Some people, such as patients with insulin resistance and/or hypertriglyceridemia, may have low or normal LDL cholesterol content, but still have a high concentration of small, dense LDL particles, which are thought to be more atherogenic than larger LDL particles.

Apolipoprotein B, also known as apoB, appears to be a more accurate way to determine total number of LDL particles and risk of cardiovascular disease compared to LDL cholesterol.  The ratios of total cholesterol to HDL cholesterol (should be <3) and triglyceride concentrations to HDL cholesterol (should be <2) are also predictors of risk that appear to be more important than LDL cholesterol.   A healthy cholesterol diet should address all of these markers.

Genetics, Diet and Blood Cholesterol

About 25% of the population has a gene (apo E4) that is associated with abnormal cholesterol metabolism and a high risk of cardiovascular disease.   For this group, a low-fat diet has been associated with improvements in blood cholesterol and other markers.  For the rest of the population (apo E2, apo E3), a low-fat diet is NOT always linked with improvements in blood cholesterol markers.  Moderate alcohol intake does appear to be protective for the majority of the population, but for the 25% with the apo E4 gene, moderate alcohol has been linked with adverse effects on blood cholesterol.  A healthy cholesterol diet should address both genetic and other markers.


Bottom Line: What Should You Do? Healthy cholesterol diet, other

Nutrition science indicates that a comprehensive diet and lifestyle modification is often most effective for improving health outcomes.   The combination of multiple dietary factors is often more powerful than a single factor alone.  Studies suggest there are more to beneficial effects from “whole food” dietary therapy rather than just lipid management.  And focusing on just one food component or one micronutrient can lead to imbalances and has lead to harm.  Use a whole food diet approach and consider all of these factors as part of a healthy cholesterol diet:

1.  Moderate, quality dietary fat,  30% of your total calories from fat (lower LDL; may also decrease small particle LDL %, increase HDL):

Emphasize monounsaturated fats (50% of total fat intake), polyunsaturated fats (40% of total fat intake): omega-3 fats from fish oil (cold water, fatty, low mercury fish 2-3 times per week) and plant sources and quality, unrefined omega-6 fats and oils, quality saturated fats (10% of total fat intake), eliminate rancid, oxidized “damaged” fats such as processed, industrial vegetable oils and food products that contain these oils, trans fats and fried foods.  

*Healthy cholesterol diet if you have apo E4 genotype: follow a low-fat (<30% of total calories) - especially saturated fat, low cholesterol (300 mg/day cholesterol) diet that includes cysteine (yogurt, poultry, oats) and glutathione-rich foods (asparagus, avocados, walnuts, undenatured whey protein).  You may consider experimenting with a very low-fat (10% of total calories) vegetarian type diet similar to the Ornish diet and lifestyle program.

**For triglyceride lowering (may also increase HDL; decrease small particle LDL %) it is recommended that you take      2-4g/day of quality fish oil (combined EPA and DHA). Supplementing with Gamma linoleic acid (GLA) such as, evening primrose oil is also suggested in order to maintain fatty acid balance.  Use caution if you also take blood-thinning medications.

2.  Low glycemic impact diet, 40% or lower of your total calories from carbohydrate (decrease triglycerides; may also increase HDL; decrease small particle LDL %; help with reversing insulin resistance, metabolic syndrome):

Avoid all types of refined sugars, high-glycemic carbohydrates, focus on low-glycemic fruits, non-starchy vegetables, legumes and whole, intact grains.

High fructose corn syrup (HFCS) deserves its own paragraph.  HFCS is rapidly metabolized and bypasses many of the body’s regulatory systems.  It negatively affects blood cholesterol levels, triglyceride concentrations, and other markers of cardiovascular disease risk (i.e. contributes to fatty liver which exacerbates insulin resistance).  Eliminate it as part of your healthy cholesterol diet.

*If you have ApoE4 genotype the percentage of calories from carbohydrate may need to be increased.

3. Plant sterols and stanols are natural fatty substances found in all plants, a class of phytonutrients that have proven beneficial for lowering LDL cholesterol and possibly other markers of heart disease (decrease LDL; decrease apoB). However, new research links high blood sterol levels and heart disease risk.

It is recommended that patients with dyslipidemia consume plant sterols/stanols at 2 g/day in supplemental capsule form or in the form of sterol/stanol-enriched foods (ie. Promise Activ, Benecol brands) as part of a healthy cholesterol diet. For optimal results, the plant sterols should be taken with mixed fiber, monounsaturated fats such as olive oil or nuts and omega-3 fats.   Most of the plant sterol/stanol enriched food products contain unhealthy ingredients and some contain sterols/stanols in a form that may not help lower cholesterol.  Plant sterols are only a small part of a healthy cholesterol diet and I believe focusing on other strategies may be a better idea.

 4. Soy protein:  Replacement of animal protein with vegetable derived protein has been associated with the reduced risk of cardiovascular disease and a reduction of serum cholesterol levels (decrease LDL, triglycerides in individuals with elevated serum lipids) and other markers of cardiovascular disease risk (decrease apoB).   Incorporate 25 g/day of  organic, non-GMO traditional soy foods (fermented is best) as part of your healthy cholesterol diet and avoid soy/isoflavone supplements.

What does 25 grams of soy protein look like?  3 ounces water packed tofu = 6 to 13 grams, 1/4 cup (1 ounce) unroasted soynuts =12 grams, 1/2 cup (4 ounces) tempeh = 16 to 22 grams, 2/3 cup (3 ounces) edamame = 6 grams.

5. High soluble fiber (decrease LDL) and fiber rich foods: Soluble fibers such as oats, barley, psyllium, pectin and guar gum have been associated with lowering total and LDL cholesterol levels and reducing cardiovascular disease risk.  Your total fiber goal for the day should be 30-50 grams, with at least 10 grams from soluble fiber.  Consider supplementing with a quality psyllium fiber (powder) if necessary. *High fiber products can interfere with nutrient absorption, so take your multivitamin/mineral 1 hour before.

6.  Alcohol: If you drink, maintain a moderate alcohol intake (increase HDL; may decrease LDL): Consumption of alcoholic drinks by otherwise healthy people seems to reduce the risk of developing cardiovascular disease. Moderate alcohol use (one to two drinks per day) reduces the risk of coronary heart disease, atherosclerosis, and heart attack compared with nondrinkers.

*If you have apoE4 genotype, lower or avoid alcohol.  High alcohol intakes are also associated with elevated triglyceride levels.  Alcohol (3+ glasses per week) is associated with increased breast cancer risk, so I would recommend women keep alcohol at 3 or less drinks per week and focus on other strategies for reducing risk of cardiovascular disease.

7. Drink green tea: 3+ cups per day

Consider trying out a high cholesterol meal plan and recipes (use promotional code "Vitality 1" on the "Sign Up Now" page for 15% off your subscription) from the experts at MyFoodMyHealth as part of your first steps.

Nutritional supplements: Its best to use testing to guide supplementation. Antioxidants and micronutrients should be adjunctive therapy to optimal nutrition, exercise, weight reduction and other therapies.  In general, don’t take high doses of only one or two vitamins or minerals – remember that nutrients work together - and for some populations this has shown to be harmful.  

Choose a high quality daily multivitamin with chelated minerals: a quality, professional line supplement means a higher cost, but contains the most bio-available formula.  Some studies have documented a modest but significant reduction in serum lipids with long- term consumption of oral probiotics (mixed strains, about 5 billion per day).  Try to incorporate foods with naturally occurring probiotics daily (ie. plain, Greek yogurt, sauerkraut) or consider supplementing.   Some experts suggest targeted nutritional supplementation (in appropriate doses, combinations and in conjunction with optimal diet and lifestyle changes) such as, 200 mg mixed tocotrienols per day, pantethine, niacin, curcumin, artichoke extract, coenzyme Q10, plant sterols and green tea extract for the management of dyslipidemia and reduced cardiovascular disease risk.

Consider additional testing to personalize your healthy cholesterol diet:  A fasting lipid panel is usually part of a standard physical exam.  If this test indicates abnormal cholesterol levels then consider additional testing to assess your LDL particle size, apo E genotype as well as other markers that may help manage your individual health condition.  In general, low vitamin D levels are associated with chronic disease risk and this includes cardiovascular disease.   Check your vitamin D levels and supplement with vitamin D3 based on your blood levels (aim for 50-80 ng/dL). 

This is a general guide to a healthy cholesterol diet and will need to be modified based on your health condition.  Other factors such as stress management, adequate sleep, exercise and weight reduction are also important for prevention and management of abnormal cholesterol and cardiovascular conditions.   I hope this page gives you some updated information on ways you can modify your diet to help manage and support your health.

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Some references:  Textbook of Functional Medicine; Clinical Nutrition: A Functional Approach, 2nd Ed., 2004; IFM Functional Nutrition course, 2012;  Astrup et al. The role of reducing intakes of saturated fat in the prevention of cardiovascular disease: where does the evidence stand in 2010? Am J Clin Nutr 2011;93:684–8.; Siri-Tarino et al. Saturated fat, carbohydrate and cardiovascular disease Am J Clin Nutr 2010;91:502–9.  Houston et al. Nonpharmacologic treatment of dyslipidemia. Progress in Cardiovascular Disease 2009 (52): 61-94; Berkeley Heart Lab, Inc.  – references; Ornish, D., The Spectrum, 2007; Natural Medicine Comprehensive Database             


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