Q:I'm a 40-year-old woman and just found out from a blood test that I have high cholesterol. As a first step, I want to try lowering it through diet – but I already avoid foods that are high in cholesterol. A friend told me that fats and oils affect cholesterol levels, too. Can you explain?
Answer provided by Terese Scollard, MBA, R.D., L.D., regional clinical nutrition manager for Providence Nutrition Services, and Jodi dePinna, R.N., cardiac educator for Providence Heart and Vascular Institute: Foods high in dietary cholesterol – including animal products such as egg yolks, butter, shellfish, liver and kidneys – can raise your cholesterol. But it's true that saturated fats and trans fats are bigger villains.
In doing something about your blood cholesterol level, you are doing something about your risk of coronary heart disease. Smart! Coronary heart disease leads to heart attacks; it's the number one cause of death for both men and women. High blood cholesterol also increases the risk of stroke.
Your body needs cholesterol for various functions, but it manufactures all it needs. When too much cholesterol is running around in the blood, it can contribute to artery damage and heart disease.
Your doctor could be concerned with any of three results from your blood test: too much LDL cholesterol, too little HDL cholesterol or too many triglycerides.
You probably know that cholesterol is divided into two types:
Low-density lipoprotein (LDL), the so-called “bad” cholesterol. When LDL is in oversupply, it tends to lodge itself in the smooth inner lining of the arteries, especially the arteries leading to the heart. Deposits of fat and cholesterol inflame, roughen and clog the artery walls with atherosclerotic plaques. As a result, blood, with its cargo of oxygen and nutrients, does not flow as easily. A blood clot moving through your circulatory system is more likely to snag and catch in a narrowed, roughened artery. If a clot blocks a key artery, it can lead to a heart attack or stroke. To keep your risks low, LDL levels should be less than 100 mg/dL.
High-density lipoprotein (HDL), or “good” cholesterol. HDL cholesterol helps prevent LDL cholesterol from building up in arteries by carrying the cholesterol to the liver for processing and elimination. You want your HDL level to be 60 mg/dL or higher.
Triglycerides are another type of fat that travels in your blood stream. If your triglyceride levels are too high, your potential for heart disease is higher. A healthy triglyceride level is less than 150 mg/dL.
Our genes can predispose us to unhealthy levels of LDL, HDL or triglyceride. Even if that's the case, most people still can greatly affect their blood cholesterol levels through diet, exercise, and, if needed, weight loss and tobacco cessation. It's great to try these lifestyle changes before turning to cholesterol-lowering drugs, because drug therapies can have side effects.
Here are steps to take that can deliver a big impact, depending on your current habits. (Make these changes in moderation and as part of a balanced diet.)
1. Significantly reduce the saturated fats and trans fats in your diet and replace them with monounsaturated and polyunsaturated fats. Why: Reducing saturated and trans fats is the single biggest dietary change you can make to reduce blood cholesterol levels.
At the grocery store: Instead of butter, stick margarine, shortening, full-fat cheeses and cream, go for very soft or liquid margarine, olive and canola oils. Try a favorite cheese in a low-fat version. Add sliced avocado (high in monounsaturated fat) instead of cheese to a turkey sandwich. Splash low-fat milk instead of half-and-half in your coffee. Trans fat occurs naturally in some foods, but the most problematic source is commercial baked goods. Check labels of crackers, cakes, chips and cookies for partially hydrogenated or hydrogenated fats or shortening – and if you see it on the label, leave it on the shelf.
Note: The Food and Drug Administration has changed labeling regulations regarding trans fat. By Jan. 1, 2006, trans fat content must be included on food labels; manufacturers are phasing in those packaging changes. Read more about trans fat and other types of fats.
2. Eat fish two or three times a week. Why: Fish contains varying amounts of two kinds of omega-3 fatty acids: eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA). Omega-3 fatty acids are a type of polyunsaturated fat. When you eat foods high in omega-3s in place of foods high in saturated fats, blood cholesterol levels fall. Omega-3s also lower blood pressure, reduce the risk of heart attack, and help keep the heart beating regularly.
At the grocery store: Different fish and shellfish have differing amounts of omega-3 fatty acids, with fatty and cold-water fish having higher amounts. Salmon, albacore or bluefin tuna, trout, halibut, anchovies, sardines, mackerel and herring are especially good sources. One serving size is four to six ounces, or a piece about the size of the palm of your hand.
Note: A study published in January 2005 in the Archives of Internal Medicine suggests that fried fish and fish burgers do not offer the same protective effects against stroke as non-fried fish. Researchers don't know whether the difference was due to the way the food was prepared or to the type of fish (white fish) that ordinarily ends up fried or in fish burgers.
3. Eat non-fish sources of omega-3s. Why: Certain plants offer alpha-linolenic acid (ALA), a third kind of omega-3 fatty acid. ALA is less potent than EPA and DHA, but it may improve the ability of arteries to expand, and it may protect the heart against potentially fatal rhythm disturbances (the research on this isn’t firm yet).
At the grocery store: Good sources of ALA are canola oil, soybeans, tofu, ground flaxseed, many leafy green vegetables, English walnuts and some salad dressings.
Note: The Nurses Health Study found that women who reported eating diets rich in alpha-linolenic oils seemed to have a lower risk of dying from heart disease and sudden cardiac death than women with diets scant in ALA. The results were reported at the American Heart Association’s Scientific Sessions in November 2004.
4. Caution: Don't start gobbling fish oil capsules.
Why: Health practitioners do not recommend fish oil capsules for the general public. An overload of omega-3 fatty acids can alter your blood's ability to clot or can cause excessive bleeding. The doctor, nurse or dietitian working with you to lower your blood cholesterol will be in the best position to decide whether fish oil is a prudent way to gain some of the health benefits offered by the omega-3s in fish.
At the grocery store: Don't buy fish oil capsules on a whim. The dosage and frequency of fish oil consumption need to be closely supervised by a medical professional.
5. Eat 10 to 25 grams of soluble fiber per day. Why: Think “roughage" when you think fiber. Fiber is either soluble or insoluble. Both types offer health benefits, but soluble fiber is a champion at helping control cholesterol. Over time, every gram of soluble fiber you eat daily will reduce your LDL cholesterol by .5 to 1 percent.
At the grocery store: Foods high in soluble fiber include oatmeal, oat bran, rye, barley, ground flaxseed, sunflower seeds, dried beans, avocados, broccoli, carrots and other vegetables, apples, citrus fruits, peaches, pears, strawberries, grapes and dried prunes.
Note: If you are eating a fairly low-fiber diet now, add the extra fiber over a three-week period and be sure to drink extra water. Otherwise you can upset your digestive system.
6. Limit the cholesterol you eat. Why: Your body makes its own cholesterol. That production is supposed to slow down as you add cholesterol from your diet. But the system doesn't always function perfectly. The Institute of Medicine and other experts recommend that people with LDL levels higher than 130 mg/dL limit their dietary cholesterol intake to 200 mg a day. (The recommended limit for others is 300 mg daily.) Individuals vary in how their blood cholesterol level responds to changes in dietary cholesterol, but because you have high cholesterol already, cutting down more severely is a good move. Your next fasting blood test will show if your body responds to this kind of dietary manipulation.
At home: Experiment with using egg substitutes or egg whites instead of whole eggs. If the recipe calls for two eggs, for example, try egg substitutes or one egg plus two egg whites. If you crave a hard-cooked egg, make a medium-sized one, which has less cholesterol than a large. Remember to count the eggs and butter used in baking and cooking.
Note: One large egg has 213 mg of cholesterol. The cholesterol, along with a lot of nutrition, is all in the yolk. The egg white is protein. Read the American Heart Association's position on eggs.
7. Make sure your overall fat intake stays between 20 and 30 percent of your total calories. Why: Our bodies are tuned to eat a balance of carbohydrates, fat and protein. If you have high cholesterol, consuming too much fat can worsen your cholesterol and triglyceride levels. For people with certain genetic predispositions, cutting fat consumption too drastically also can throw off the balance of fats in the blood, which can raise triglyceride and LDL levels.
At the grocery store: For protein, turn to lean meats and skinless poultry, low-fat cheeses, low-fat or nonfat milk and yogurt, egg whites and, of course, fish. Incorporate whole grains, fruits, vegetables and legumes into your daily diet. Choose your fat calorie sources thoughtfully. If you love cheese, or butter, or chocolate, you can have them – just make a trade-off with other high-fat foods so you don't go over your total allowed amount.
Note: Limit saturated fat to 7 percent of total calories, or about a quarter of your total fat calories. (For those with normal blood cholesterol, the recommended limit is 10 percent, or about a third of total fat calories.)
You can do even more, on top of eating right.
Exercise increases HDL cholesterol and decreases LDL, so you get a two-way improvement by stepping up your activity. The federal government currently recommends 30 to 60 minutes of moderately intense physical activity most days of the week; but if you are pressed for time, doing some is better than doing none.
If you are not already at a healthy weight, achieving and maintaining a healthy weight will help normalize your various cholesterol levels. Even a small loss, such as 5 to 10 percent of your body weight, can make a big difference in your health.
If you smoke, quit. And avoid secondhand smoke. Tobacco smoke damages the heart and blood vessels, making narrowed arteries and heart attack more likely. Nicotine may increase the stickiness of blood cells, making them more likely to adhere to artery walls.
Consider meeting with one of Providence's registered dietitians, who can help tailor a strategy that best fits your health history, age and situation. (Your health plan may provide a covered benefit for nutrition counseling; check your policy.) The tips provided here are good general advice, but a one-on-one consultation will give you even more ideas for achieving your goal.
Work on making these changes for about four to six months, then ask your physician to order another full lipid panel. This will provide useful feedback on how your program is working and whether you need help from cholesterol-lowering medication.
Meanwhile, your body will be giving you feedback week by week as you improve your health habits. We're betting you'll feel great!
