May 13, 2020
Naveed Saleh, MD, MS, for MDLinx
Although statins are remarkably effective at lowering lipid levels, they have been mired in controversy, an imbroglio commonly referred to as the “statin wars.” Much of this controversy centers on the benefits of statins as primary prevention vs their adverse effects, most disconcertingly acute renal failure due to rhabdomyolysis.
Fortunately, there may be natural alternatives that lower cholesterol levels without the rare but real risks inherent in statin use.
Higher monounsaturated fat intake
Higher intake of monounsaturated fat can raise high-density lipoprotein (HDL) cholesterol without increasing low-density lipoprotein (LDL) cholesterol, with corresponding reductions in cardiovascular disease (CVD) risks.
In a small study published in the Canadian Medical Association Journal, researchers examined the effects of either high or low intake of monounsaturated fats in 24 patients on a 1-month low-saturated-fat diet (a diet previously shown to lower LDL cholesterol). They found that levels of HDL cholesterol increased by 12.5%, the ratio of total cholesterol to HDL dropped by 6.5%, and LDL cholesterol did not increase in those consuming a diet high in monounsaturated fats.
“Monounsaturated fat increased the effectiveness of a cholesterol-lowering dietary portfolio, despite statin-like reductions in LDL cholesterol. The potential benefits for cardiovascular risk were achieved through increases in HDL cholesterol, further reductions in the ratio of total to HDL cholesterol, and reductions in C-reactive protein,” they wrote. C-reactive protein is a biomarker of inflammation linked to higher CHD risk.
They added: “Raising HDL cholesterol by increasing the intake of monounsaturated fat may also have dietary appeal, not only as part of the Mediterranean diet but also because olives, avocados, nuts, and canola and olive oils are potentially rich sources of monounsaturated fat.”
Fat substitution
Replace saturated fats with polyunsaturated fats. In a systematic review and meta-analysis published in PLoS Medicine, researchers investigated whether increased consumption of polyunsaturated fatty acids (PUFA) in place of saturated fatty acids (SFA) could affect coronary heart disease (CHD) outcomes.
“[I]ncreasing PUFA consumption as a replacement for SFA reduced the occurrence of CHD events by 19%,” they concluded. “This suggests that rather than trying to lower PUFA consumption, a shift toward greater population PUFA consumption in place of SFA would significantly reduce rates of CHD.”
Foods high in polyunsaturated fats include sunflower, corn, soybean, and flaxseed oils, as well as walnuts, flax seeds, fatty fish (salmon, tuna, mackerel, herring, trout, sardines), soymilk, and tofu.
Eschewing all trans fats
Are all trans fats bad? We all know that industrially-produced trans fats (iTFA) are slow-acting poison and should be avoided at all costs. But what about trans fats produced naturally from cows, sheep, goats, and other ruminant animals?
In a double-blind, randomized controlled trial published in the American Journal of Clinical Nutrition, researchers found that vaccenic acid (VA) and cis-9,trans-11 conjugated linoleic acid (c9,t11-CLA), which are trans fats naturally occurring in ruminant animals, do indeed negatively impact lipid levels.
Here’s a bite of their results: “Total cholesterol (TC), LDL cholesterol, triacylglycerol, lipoprotein(a), and apolipoprotein B were higher after VA than after iTFA; high-density lipoprotein (HDL) cholesterol and apolipoprotein AI also were higher after VA. Compared with control, VA and iTFA both increased TC, LDL cholesterol, ratio of TC to HDL cholesterol, and apolipoprotein B (2-6% change; P < 0.05); VA also increased HDL cholesterol, apolipoprotein AI, apolipoprotein B, and lipoprotein(a) (2-6% change; P < 0.05), whereas iTFA did not. c9,t11-CLA lowered triacylglycerol (P ≤ 0.01) and had no effect on other lipoprotein risk factors.”
In short, naturally-produced trans fats are just as bad, if not worse, than industrially-produced trans fats. So, avoid both kinds.
Fiber consumption
Include fiber as part of a low-carb diet.
Per the results of a double-blind, placebo-controlled trial published in Metabolism, researchers found that in 30 overweight/obese men randomly assigned to supplement a carbohydrate-restricted diet (CRD) with fiber, lipid levels dropped further and faster in those taking fiber compared with those taking placebo. However, consuming fiber did not provide any additional benefits with respect to plasma triacylglycerol and HDL levels.
“We conclude that the consumption of a CRD by overweight men provides multiple improvements of cardiovascular risk profile, and LDL-C levels may be more rapidly reduced and stabilized through the addition of 3 g of soluble fiber per day,” the researchers wrote.
Citrus fruits consumption
Compounds in citrus fruits have lipid-lowering effects. Sources tested in humans include orange and grapefruit juices.
In a review article published in Current Opinion in Lipidology, researchers suggested that flavonoids found in citrus fruits moderate lipid metabolism and other metabolic processes that play key roles in heart disease, metabolic syndrome, and type 2 diabetes.
“These recent studies suggest an important role of citrus flavonoids in the treatment of dyslipidemia, insulin resistance, hepatic steatosis, obesity and atherosclerosis. The favorable outcomes are achieved through multiple mechanisms. Human studies focused on dose, bioavailability, efficacy and safety are required to propel the use of these promising therapeutic agents into the clinical arena,” they concluded.
Taking supplements
Based on the evidence, certain supplements may be effective at lowering lipid levels:
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Blond psyllium (found in Metamucil) may decrease total and LDL cholesterol levels
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Flaxseed may decrease LDL cholesterol levels
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Fish oil may decrease triglyceride levels
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Green tea/green tea extract may decrease LDL cholesterol and triglyceride levels
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Niacin may decrease LDL cholesterol and increase HDL cholesterol levels
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Oat bran may reduce total cholesterol and LDL cholesterol
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Plant sterols may decrease total and LDL cholesterol levels
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Soy protein may decrease LDL levels
Exercise
Finally, in a landmark study published in the New England Journal of Medicine, researchers found that only when aerobic exercise was combined with a low-fat diet did LDL levels drop in adults with low HDL levels and moderately elevated LDL levels. A low-fat diet alone didn’t do the trick.
“These data strongly support recommendations to add exercise to diet for the management of lipoprotein levels associated with a high risk of coronary heart disease,” they concluded. “Together with our previous findings, they suggest that weight loss should be further emphasized, when appropriate, particularly in counseling men and women who have both low HDL cholesterol levels and elevated LDL cholesterol levels.”
The researchers did not provide suggestions for specific aerobic exercises that could lower cholesterol. But, good examples of aerobic exercises include cycling, swimming, walking, elliptical machines, and step machines.
In summary, before prescribing or taking statins, consider implementing some or all of these basic approaches that don’t have serious side effects.