Tackling high cholesterol: Is there an alternative to taking statins?

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1 Advice from our consultant dietitian Helen Bond Tackling high cholesterol: Is there an alternative to taking statins? The National Institute for Health and Care Excellence (NICE), the Government s public health watchdog issued guidance last month that statins - cholesterol lowering drugs - should be prescribed more widely. (Ref 1) But if statins are not for you, what are the natural alternatives to lower your cholesterol levels, and reduce your risk of developing cardiovascular disease (CVD). As the consultant dietitian to St Helen s Farm, I am here to explain what cholesterol is, why it s important to have your blood cholesterol checked out and the key dietary and lifestyle changes to bring those levels down - and keep them there. HEART AND CIRCULATORY DISEASE IS THE UK S BIGGEST KILLER Although death rates have halved since the 1970s and 80s, diseases of the heart and circulation are responsible for more than 1 in 3 deaths in both men and women in the UK that s around 180,000 people each year. (Ref 2)

2 WHAT PUTS YOU AT RISK? There are many risk factors for CVD and the more you have, the greater your chance of developing the condition. Some of which you cannot change, including your age, sex, ethnicity, and family history but the good news is that there are many factors that you can change in your diet and lifestyle that will help reduce your cholesterol, your blood pressure, your weight and help to keep your heart healthy. (Ref 3) WHAT IS CHOLESTEROL? Most of us know how important it is to keep our cholesterol levels down, even if we re not quite sure why. Everyone has cholesterol - a hard, waxy substance - some of it comes from the food we eat, but most of it is made in our liver. And while it has some vital uses as a structural part of every cell membrane, as a building block for some hormones and in the production of vitamin D, for example too much can spell trouble. (Ref 4) NOT ALL CHOLESTEROL IS BAD! Cholesterol is transported around the body by special transport proteins, called lipoproteins and it is the type of lipoprotein carrier that determines its role in the body and whether it is harmful or protective. The two main types of carriers are HDL (high density lipoprotein) and LDL (low density lipoprotein). LDL is known as bad cholesterol because excess can build up inside the wall of the blood vessels, which can lead to a heart attack or stroke. HDL or good cholesterol helps to remove LDL bad cholesterol from the blood, so the more of the good kind you have the better. (Ref 4)

3 HOW TO INTERPRET YOUR CHOLESTEROL NUMBERS If you are aged between 40 and 74 years, you will be invited by your GP to have an NHS Health Check. A free midlife MOT to check your circulatory and vascular health. Among other things, your cholesterol, will all be checked and your results given to you. (Ref 5) It s measured in units called millimoles, per litre of blood (mmol/l). Ideally, your total cholesterol level should be less than 5mmol/L, your LDL bad cholesterol should be no more than 3mmol/L, and good HDL cholesterol should be more than 1mmol/L. (Ref 4) Around 6 out of every 10 adults in the UK have cholesterol readings above the desired level (Ref 4) and the World Health Organisation estimates that around 20% of strokes and over 50% of heart attacks can be linked to high levels. (Ref 6) But, reassuringly, if you are one of the many people who have dodged the test for fear of the result, this is one health problem that we can all do something about. Remember high cholesterol is the one health problem that we can all do something about, so it s important to get tested. SHOULD WE ALL TAKE STATINS? Statins work by blocking the production of cholesterol in the liver. Despite some controversy with side effects like muscle pain, they re seen as a safe and effective treatment at reducing high cholesterol. (Ref 7) So much so, that NICE has proposed in its new recommendations on lipid modification that in order to make progress in the battle against heart disease and stroke, the threshold for GPs offering to prescribe statin should be halved from the current 20% risk (1 in 5 chance of

4 having a heart attack or stroke in the next 10 years) to a lower 10% risk (a 1 in 10 chance). (Ref 1) GPs calculate your level of risk by looking at factors such as whether or not you smoke, your cholesterol levels, blood pressure and body mass index. Yet, while most doctors agree that cholesterol-lowering statins are vital when it comes to people who have had a heart attack or stroke, to prevent a second one or for those at high risk of having a first heart attack, there are hugely differing views on whether otherwise healthy people with borderline high cholesterol should be given the drug routinely or whether a better approach is to take regular exercise, improve our diet, loose weight and not smoke. Adopting a healthier diet and lifestyle should always be the first step for tackling raised cholesterol whether you are, or are not, prescribed a statin. (Main, 2011) (Ref 8) FOOD AND LIFESTYLE STEPS TO HEALTHY CHOLESTEROL LEVELS My expert food and lifestyle steps to healthy cholesterol levels are easy to incorporate into your daily life and could make all of the difference when it comes to preventing and tackling high cholesterol. REDUCE SATURATED FAT Advice to reduce intake of saturated fat (found in fatty meat and meat products, full fat dairy products, coconut and palm oil, biscuits, cakes and pastries and many processed and take away foods) still remains key to lowering blood cholesterol levels and should be no more than 10% of

5 total daily energy around 20g per day for adults. (Ref 1, 9) While whole goats milk has a relatively high saturated fat content (2.5g per 100ml) when compared with certain other foods, semi skimmed goats milk is low in saturated fat (1.1g per 100ml), whilst the skimmed goats milk is saturated fat free (0.07g per 100ml). It is important to highlight that there are different types of saturated fat and each have differing effects on blood cholesterol levels, with some more potent then others. Indeed, it is now thought that some saturated fats from natural sources may actually have health benefits rather than causing problems. One particular form of saturated fat called stearic acid, which is found in milk and dairy foods, now seems to deserve an especially clean bill of health, because it may actually lower cholesterol levels, when compared to other saturated fats. (Ref 10, 11) What s more, it is also worth pointing out that even whole goats milk, at 122 kcals per 200ml glass is not classed as a high fat or high saturated fat food, and while the switch to a lower fat goats milk might mean fewer calories and fat, it also means fewer fat soluble vitamins including vitamins A, D, E and K and essential omega-3 fatty acids. 5 A DAY As well as being nutrient-dense and low in energy, fruit and vegetables are a good source of cholesterol lowering soluble fibre, and vitamins, minerals that may also be beneficial for heart health. Consuming five or more portions per day of a wide variety of fruit and vegetables (400g). (Ref 12)

6 GET YOUR OATS Oats contain high levels of beta-glucan, a soluble fibre that has been shown to lower LDL bad cholesterol by up to 5% when consumed in amounts of around 3g a day. You can get 3g beta-glucan by having two to three portion of oats throughout the day in products like porridge, breakfast cereals, oat bread and oatcakes. (Ref 13, 14) GO NUTTY Consider swapping your usual mid-morning chocolate biscuit for a handful (30g) of unsalted nuts daily as a healthy snack, such as almonds, pecans, pistachios, walnuts and peanuts. High in monounsaturated fat, soluble fibre and an array of vitamins and minerals - nuts have been shown to have beneficial effects on blood cholesterol levels. (Ref 15) EGGS? DON T HOLD BACK While eggs are a food source of cholesterol, we now know this doesn t have a significant effect on blood cholesterol levels, so it is fine to enjoy eggs as part of a balanced diet. Indeed, they could even be useful for lowering cholesterol, as studies have shown people who have two eggs for breakfast or lunch feel fuller for longer and go on to consume fewer calories all day. (Ref 16, 17) DON T FORGET WHOLEGRAIN FOODS The complex nutrient profile of whole grains, especially soluble fibre, unsaturated fats and important minerals and vitamins have been associated with cholesterol reductions. Enjoy three servings a day, such as wholewheat pasta, wholemeal bread, popcorn, rye crisp breads etc.

7 (Ref 18) FOOD ENRICHED WITH STANOLS AND STEROLS Eat plant stanols and sterols enriched foods which have been clinically proven to lower LDL bad cholesterol levels by 7-10% within 2-3 weeks when eaten daily, as part of a healthy diet and lifestyle. (Ref 19, 20, 21) Research has shown that plant stanols and sterols also work alongside statins reducing LDL bad cholesterol by an additional 10%. (Ref 22) EAT OIL RICH FISH Oil rich fish, such as salmon, fresh tuna, sardines, herring and mackerel are the best dietary sources of omega-3 essential fatty acids and are famed for their heart healthy properties. Aim for at least one 140g portion a week. (Ref 23) WATCH THE ALCOHOL A couple of units of alcohol a day may provide some heart health benefits by raising HDL good cholesterol. However, it is important to keep to safe limits of no more than two to three units a day for women, and three to four units a day for men with a couple of alcohol free days every week. (Ref 24) Alcohol is also high in empty calories, so cutting down could also help you manage your weight. CONSIDER YOUR LIFESTYLE, TOO As well as making these dietary changes, there are two vital steps you can take to improve your cholesterol profile.

8 GET MOVING It is well accepted that being more active can help to keep us healthy and can help lower LDL bad cholesterol, while increasing HDL good cholesterol. Choose an activity that boosts your heart rate, such as running, swimming or walking briskly and aim for at least 30 minutes, five times a week for maximum benefit. (Ref 25, 26) STOPPING SMOKING Another good reason to quit smoking lowers HDL good cholesterol, damages the lining of your arteries and may also make blood clot more easily. Talk to your doctor for advice on giving up. (Ref 27) CONCLUSION The World Health Organization (WHO), estimates that approximately 80% of CVD is preventable, with positive changes to diet and lifestyle. (Ref 6) Whether you are taking a statin or not, there's never a better time to start looking after your cholesterol levels and future cardiovascular health with a few simple steps and changes to your diet and lifestyle you can make a real difference! Good luck Helen x

9 References 1. NICE Clinical Guideline 181. (2014) Lipid modification: cardiovascular risk assessment and the modification of blood lipids for the primary and secondary prevention of cardiovascular disease. Available online from: guidance.nice.org.uk/cg Scarborough P, Bhatnagar P, Wickramasinghe K et al. (2010) Coronary Heart Disease Statistics 2010 edition. British Heart Foundation: London 3. British Nutrition Foundation. (2005) Cardiovascular Disease: Diet, Nutrition and Emerging Risk Factors 4. Cholesterol and Health. Heart UK. The Cholesterol Charity. Available online from: 5. NHS Health Check. NHS Choices. Available online from: Health-Check.aspx.. 6. WHO. Diet, nutrition and the prevention of chronic diseases (2003) Report of a Joint WHO/FAO Expert Consultation. WHO Technical Report Series 916. Geneva 7. NICE. (2006) Technology Appraisal 94: Statins for the prevention of cardiovascular events. NICE: London 8. Main, L. (2011) An Ultimate Cholesterol Lowering Plan is Urgently Needed. The British Journal of Primary Care Nursing. Available online from: 9. Eat less Saturated fat. NHS Choices. Available online from: Hunter JE et al. (2010) Cardiovascular disease risk of dietary stearic acid compared with trans, other saturated, and unsaturated fatty acids: a systematic review. Am J Clin Nutr 91: The Dairy Council. Available online from: Five A Day. NHS Choices. Available online from:

10 13. Othman RA, Moghadasian MH, Jones PJH (2011). Cholesterollowering effects of oat b-glucan. Nutr Rev 69(6), European Food Safety Authority (2010). Scientific Opinion on the substantiation of a health claim related to oat beta-glucan and lowering blood cholesterol and reduced risk of (coronary) heart disease pursuant to Article 14 of Regulation (EC) No 1924/ Available at: Sabat, da, os. ( 010) ut consumption and blood lipid levels: a pooled analysis of 25 intervention trials. Arch Intern Med 170, Vander Wal JS, Gupta A, Khosla P, Dhurandhar NV (2008) Egg breakfast enhances weight loss. International Journal of Obesity 32: Vander Wal JS, Marth JM, Khosla P, Jen K-LC, Dhurandhar NV (2005) Short term effect of eggs on satiety in overweight and obese subjects. Journal of the American College of Nutrition 245: Miller Jones J & Engleson J. (2010) Whole Grains: Benefits and challenges. Annu Rev Food Sci Tech 1, Law M. (2000) Plant sterol and stanol margarines and health. British Medical Journal; 320: Gylling H et al. (2014) Plant sterols and plant stanols in the management of dyslipidaemia and prevention of cardiovascular disease. Atherosclerosis 232; (346e360) 21. European Food Safety Authority (EFSA). (2008) Plant Stanol Esters and Blood Cholesterol. The EFSA Journal; 825: Blair, S et al. (2000) Incremental Reduction of Serum Total Cholesterol and Low Density Lipoprotein Cholesterol With the Addition of Plant Stanol Ester Containing spread to Statin Therapy. American Journal of Cardiology; 86: Oily Fish. The British Heart Foundation. Available online from: /nutrition/oily-fish.aspx. 24. Alcohol. Heart UK. The Cholesterol Charity. Available online from ohol.pdf

11 25. Benefits Of Exercise. NHS Choices. Available online from: World Health Organization. (2000) Obesity. Preventing and managing the global epidemic. Report of a WHO consultation on obesity. Geneva 27. Smoking. The British Heart Foundation. Available online from (Accessed 1st July 2014)