Table of Contents
Table of Contents
High cholesterol is a common problem. And it’s also a complicated, somewhat controversial topic. Cholesterol is usually divided into two main types, LDL and HDL. Generally, LDL cholesterol is termed “bad” cholesterol, and HDL cholesterol is termed “good.” However, before we even discuss natural approaches for high cholesterol, we need to touch on some of the controversies about the published research on cholesterol and heart disease in general.
Statin medications for lowering cholesterol are big business. The best-selling medication of all time is the cholesterol-lowering statin drug Lipitor. The lifetime sales for Lipitor are more than $150 billion. This creates large and obvious financial incentives to encourage increased and continued prescribing of cholesterol-lowering medications.
As such, we need open and unbiased research studies to assess their efficacy. Unfortunately, the current, established structure for how cholesterol medication research is published raises some important questions and concerns.
Cholesterol studies sponsored by the industry are almost all funneled through one organization. This group of researchers has financial ties to the pharmaceutical industry. It is the only body with access to the raw data for most studies published on cholesterol therapies. This data secrecy raises serious concerns, as research has shown that reanalysis of study data from clinical trials by an independent body often finds different results. While the research group has recently expanded to include an independent oversight panel, questions remain.
One of the biggest expansions of the use of medication for lowering cholesterol was for the primary prevention of heart disease. Primary prevention is the use of cholesterol-lowering medication in low-risk patients with high cholesterol to try and prevent heart disease. A 2016 editorial in The Journal of the American Medical Association makes a strong statement about the quality of the evidence on statin medications for primary prevention. The authors state that the evidence does not even reach grade B or grade C level. In other words, the research supporting recommendations for lowering elevated cholesterol in low-risk patients is of very poor quality.
Part of the problem includes poor study methodology allowed before 2006. The majority of early studies on statin medications are potentially suspect. Interestingly, better quality clinical trials published after 2006 have generally failed to show benefits for reducing mortality with statins. If heart disease is the number one killer, and cholesterol is to blame, you would expect some definitive benefits in reducing the risks of death through lowering cholesterol.
However, that has generally not been found with the latest research. Based on all the problems, some researchers in 2016 went so far as to say that statin medications' efficacy and safety are not “research-based.” Considering this mess in the published literature on cholesterol-lowering therapies, what can we definitively recommend?
It has been well known for years that very high LDL cholesterol can result from genetic problems. Known as familial hypercholesterolemia, patients with this condition often develop heart disease at a young age. It’s considered the “model condition” that demonstrates a link between cholesterol and heart disease. And it clearly shows that really high cholesterol raises risks for heart disease and death. But like most things in medicine, the idea that cholesterol is always bad appears to be a significant oversimplification.
While highly controversial, studies have repeatedly shown either protective benefits or a reduction in harm from high cholesterol as people get older. After age 65, data suggest that higher total cholesterol, LDL cholesterol, and HDL cholesterol may be protective for overall health, decreasing mortality. Cholesterol plays a role in immune responses, protecting from infections, which may become more important as we age.
On the flip side, other data suggests that lowering cholesterol after a major heart event, like a heart attack, is beneficial. In other words, if patients currently have severe, life-threatening heart disease, lowering cholesterol is a valid approach to reduce risks of future heart problems.
If you have very high cholesterol and are under the age of 65, it typically should be reduced. In patients that have had a heart attack or those at high risk for heart problems, reducing elevated cholesterol is also likely effective in preventing future events. In other situations, due to problems in the published research, it’s difficult to know what’s best. We are in desperate need of additional unbiased clinical trials. We also should likely stop referencing and relying on some of the older published studies on cholesterol-lowering therapies.
For lowering cholesterol, statin medications are the standard first-line approach. Unfortunately, some patients don’t tolerate these medications. They also increase the risk for diabetes. When indicated, natural approaches for reducing cholesterol may be a reasonable choice for some individuals struggling to reduce cholesterol levels.
Fortunately, for those that need to reduce cholesterol levels, several natural approaches can be effective.
Diet can play a role in reducing cholesterol, and the type of fats we consume can increase or decrease risks. Trans fatty acids, or trans fats, are manmade fats that have increased stability and longer shelf-life. Unfortunately, they also have a clear and negative impact on heart health.
Consuming trans fats raises LDL cholesterol and increases risks for heart attack, stroke, and death. The evidence is pretty clear that trans fats do not have a place in a healthy diet. When checking ingredient lists, any fat listed as “hydrogenated” is a trans fat and is best not consumed.
Diets high in monounsaturated fatty acids appear to have clear benefits on cholesterol and heart disease. Olive oil is high in monounsaturated fat. A large body of evidence suggests that consuming 20% of calories from monounsaturated fat reduces risks for heart events, including a reduction in heart attacks by 20%.
Nuts are also known to be heart-healthy. Numerous studies have found reduced total and LDL cholesterol with nut consumption. Generally, a serving of about 45 grams of nuts a day is a reasonable quantity. The strongest evidence is around walnuts and almonds; however, studies on hazelnuts, pecans, pistachios, cashews, macadamias, and peanuts all appear to suggest benefits.
Fiber is important for health. Some of the latest research suggests that for every seven grams of increased fiber, you reduce your risks of heart disease by 9%. Soluble fiber, the type found in oats, psyllium, and flaxseed all appear to have modest benefits for lowering total and LDL cholesterol. They likely work by binding to cholesterol in the digestive tract and eliminating it from the body.
Bergamot is a citrus fruit about the size of an orange, but with a greenish-yellow rind. It has long been used as the flavoring for Earl Grey tea. Recently, clinical trials of bergamot extract have documented cholesterol-lowering effects. A review of all the studies on bergamot for cholesterol found most showing significant benefits, with reductions in total cholesterol of up to 31% and LDL cholesterol up to 40%. The study authors concluded that bergamot appears to be a promising alternative for cholesterol management.
Phytosterols are plant steroids that have been reported to have potential anti-inflammatory and antioxidant effects. Benefits in the research suggest blood sugar balancing and cholesterol-lowering activity. Studies have found that around 2 g of phytosterols per day can lower LDL cholesterol between 8% and 10%.
Found in larger quantities in nuts, seeds, oils, beans, and whole grains, phytosterols likely contribute to these foods' heart health benefits. Phytosterols are also fat-soluble and appear to work best when taken with food and fat. In supplement form, how they were extracted and processed can be critical for achieving therapeutic benefits.
While studies have been mixed over the years on the benefits of garlic for cholesterol, the largest recent meta-analysis shows significant effects. Overall, total cholesterol was lowered by 17 mg/dl, and LDL was lowered by 9 mg/dl on average with garlic supplements. The study authors concluded that these benefits should reduce the risk of heart events by 38% in the average 50-year-old.
High cholesterol is a complex issue that needs further non-biased research to fully understand the best treatment approaches. For people under age 65 with very elevated cholesterol, or in patients who have had a heart attack or are at high risk for heart events, lowering cholesterol should help to decrease risks of worsening heart disease.
While standard approaches can lower cholesterol, natural options often have fewer side effects. In the published research, diet and several supplements, including bergamot, phytosterols, and garlic appear to provide benefits.
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