Elevated cholesterol is the nutritional issue that people are most aware about. People are basically afraid of high cholesterol, and most with it take medication, which is likely why statin drugs are the number one selling drugs in the United States. Television commercials often say that statin drugs are appropriate when diet and lifestyle changes do not work. And, since so many people are taking statins, it is easy for one to believe that diet and lifestyle do not work to normalize cholesterol.
The diet that most patients adhere to when trying to lower cholesterol is a high carbohydrate diet. The Food Pyramid is the best example of a dietary approach that allows almost an unlimited amount of starchy carbohydrates. In fact, during a five-day sample Food Pyramid diet, we are allowed over ten servings of white flour products and over ten teaspoons of margarine. There is no way one can lower cholesterol on the bread and margarine diet, as you will see below.
When considering the issue of cholesterol levels, there are three important metabolic/dietary factors that lead to increased levels of cholesterol. There is likely to be a cumulative effect when each is present.
1. Trans fats from margarine, deep-fried foods, and most packaged foods, cause LDL cholesterol levels to rise, and HDL cholesterol to lower.1
2. High glycemic index/load foods cause HDL cholesterol levels to drop, which means most desserts, all refined grains, and certain whole grain products are a problem.1
3. Insulin stimulates the enzyme HMG-CoA reductase, which is the rate-limiting enzyme in cholesterol synthesis, and its activation leads to cholesterol production.2 That insulin stimulates HMG-CoA reductase has been known for many years. The book referenced here2 was published in 1987. Thus, twenty years later, we are a nation riddled with syndrome X and type II diabetes, which act as drivers of cholesterol synthesis. As opposed to vigorously working to reduce hyperinsulinemia, multiple millions of Americans take statin drugs which, interestingly, function by inhibiting HMG-CoA reductase, the precise enzyme that insulin stimulates to increase cholesterols synthesis.
Hyperinsulinemia is a component of syndrome X, which is often referred to as pre-diabetes. It is estimated that as many as 75 million Americans may be suffering with syndrome X. In general, insulin levels rise when insulin sensitive tissues, such as skeletal muscle, become resistant to the actions of insulin. Several factors are known to promote hyperinsulinemia and insulin resistance, such as an increased intake of omega-6 fatty acids, and a reduced intake of chromium, magnesium, and potassium.3-5 Inadequate exercise and excess body fat, particularly visceral adiposity, also promote insulin resistance.6
With the above in mind, it is not surprising that many fail to lower their cholesterol levels, as the average patient does not exercise adequately and eats far too few mineral-rich fruits and vegetables, and too many flour products. Considering this relationship between lifestyle and cholesterol, we could begin to view cholesterol levels as a wellness marker. This is because, generally speaking, unless one has a familial hypercholesterolemia issue, the only reason for inappropriately elevated levels of cholesterol is an unhealthy lifestyle, i.e., a lack of wellness efforts.
What is the ideal level of cholesterol that we should pursue with lifestyle modifications? As far as I can tell, no one knows for sure; however, we have some clues to consider. Cordain has recently reviewed the cholesterol literature and pointed out that atherogenesis was halted when LDL cholesterol levels were reduced to 79 mg/dL with statin drugs (80 mg/d of atovorastatin).7
Regarding total cholesterol, it appears that levels reach 200 or higher only in modern humans. No other mammals, and no hunter-gatherer-like populations have total cholesterol above 150 mg/dL. Even the Inuit Eskimos have total cholesterol levels at 150 mg/dL or less.7
Previous to reading the work of Cordain, et al.,7 I was hesitant to believe a cholesterol level greater than 200 should be viewed with concern. My reason for this view is because there are inconsistencies regarding the groups of individuals for whom elevated cholesterol levels predict cardiovascular disease.8 Additionally, of the people who died in the Framingham group from heart disease, 80 percent of them had the same cholesterol levels as those who did not.9
We also know that heart disease is driven by complex mechanisms that function irrespective of total cholesterol levels. For example, atherosclerosis is known to be an inflammatory disease.10,11 In this regard, we know that elevated C-reactive protein levels are more predictive of heart disease than LDL cholesterol levels.12
Despite the variables mentioned in the previous paragraph, it seems likely that cholesterol levels may best serve as a measure of some key lifestyle choices. For example, when a patient presents to your office with elevated cholesterol (200 or higher), this should alert you to carefully investigate their lifestyle, particularly blood sugar regulation (blood glucose, hemoglobin A1C, insulin), and intake of trans fats, sugar, and domesticated (grain-fed) animal products.
Recent studies have suggested that garlic and policosanol are ineffective at lowering cholesterol, and this should not be viewed as surprising. We should not expect that single supplements would have the power to counteract the cumulative effects of the pro-inflammatory dietary factors described above.
Dietary changes are a must for lowering cholesterol and reducing the pro-inflammatory state. In addition to anti-inflammatory eating, several supportive supplements can be added, such as a multivitamin, magnesium, fish oil, vitamin D, and probiotics. Each of these supplements has anti-inflammatory biochemical effects that are beneficial in all conditions associated with the pro-inflammatory state.
Dr. Seaman is the Clinical Chiropractic Consultant for Anabolic Laboratories, one of the first supplement manufacturers to service the chiropractic profession. He is on the postgraduate faculties of several chiropractic colleges, providing nutrition seminars that focus on the needs of the chiropractic patient. He is also a faculty member at Palmer College of Chiropractic Florida, where he teaches nutrition and subluxation theories. He can be reached by e-mail at [email protected].
References
1. Cordain L, Eaton SB, Sebastian A, Mann N, Lindeberg S, Watkins BA, O’Keefe JH, Brand-Miller J. Origins and evolution of the western diet: Health implications for the 21st century. Am J Clin Nutr. 2005;81:341-54.
2. Champe PC, Harvey RA. Lippincott’s illustrated reviews: biochemistry. Lippincott: Philadelphia; 1987: p.201
3. Demigne C, Sabboh H, Remesy C, Meneton P. Protective effects of high dietary potassium: nutritional and metabolic aspects. J Nutr. 2004; 134:2903-06
4. Lopez-Ridaura R, Willett WC, Rimm EB, Liu S, Stampfer MJ, Manson JE, Hu FB. Magnesium intake and risk of type 2 diabetes in men and women. Diabetes Care. 2004; 27:134-40
5. Simopoulos AP. Essential fatty acids in health and chronic disease. Am J Clin Nutr 1999; 70(3 Suppl):560S-569S
6. Grimble RF. Inflammatory status and insulin resistance. Curr Opin Clin Nutr Metab Care 2002; 5:551-559
7. O’Keefe JH, Cordain L, Harris WH, Moe RM, Vogel R. Optimal low-density lipoprotein is 50-70 mg/dl: lower is better and physiologically normal. J Am Coll Cardiol. 2004; 43(11): 2142-46
8. Ravnskov U. High cholesterol may protect against infections and atherosclerosis. Q J Med 2003; 96:927-34
9. German JB, Dillard CJ. Saturated fats: what dietary intake? Am J Clin Nutr 2004; 80:550-59
10. Ross R. Atherosclerosis – an inflammatory disease. New Eng J Med 1999; 340:115-26
11. Libby P, Ridker PM, Maseri A. Inflammation and atherosclerosis. Circulation 2002; 105:1135-43
12. Ridker PM. Cardiology Patient Page. C-reactive protein: a simple test to help predict risk of heart attack and stroke. Circulation. 2003; 108(12):e81-5.