Hyperlipidemia

Heart attacks kill more Americans than any other disease, and high cholesterol increases your risk. Cholesterol levels are directly impacted by lifestyle and diet.

High cholesterol affects more Americans than it should. 

Almost 94 millions adults in the U.S. have total cholesterol levels higher than 200 mg/dL, whilst 28 million have levels higher than 240 mg/dL, optimal levels are 150 mg/dL or lower (Virani et al., 2021)

This is a problem, because high cholesterol is a major risk factor for heart disease, the leading cause of death in the US, as well as stroke, which an American suffers from every 40 seconds (CDC, 2022)

Here, we dive into what high-cholesterol is, its risks, and how plant-based lifestyle medicine can both prevent and reverse it. 

What is hyperlipidemia? 

Hyperlipidemia is where your blood has too many lipids (fats), such as cholesterol and triglycerides. 

Hypercholesterolemia is one type of hyperlipidemia where you have high cholesterol levels; specifically, you have too much LDL cholesterol and non-HDL cholesterol in your blood

What is cholesterol and why do we need it?

Cholesterol is a waxy substance made in the liver. It’s not required in the diet, because the liver makes all the cholesterol we need.

It’s an essential part of our cell membranes, and is needed to make hormones, vitamin D, and bile acids (that help to digest fat), all of which are essential for a healthy body. 

Cholesterol travels through our bloodstream attached to lipoproteins. These have specific proteins on their surfaces called apolipoproteins. Cholesterol is carried by different lipoprotein packages which make, for example, LDL-cholesterol and HDL-cholesterol. 

What does LDL and HDL cholesterol mean and why does it matter? 

Low-density lipoprotein (LDL) cholesterol is commonly known as the ‘bad’ cholesterol. It’s responsible for transporting cholesterol through the body and is the vehicle for cholesterol to be deposited in your arteries, leading to atherosclerosis, hence its bad reputation. Cholesterol can be carried by more, small LDL particles or fewer, large LDL particles. Small, dense LDL is more associated with heart disease risk as it increases the number of Apolipoprotein B (ApoB)-containing lipoproteins (Pencina et al., 2015)

High-density lipoprotein (HDL) cholesterol is the ‘good’ cholesterol, because it scoops up cholesterol hanging around in the blood and takes it back to the liver. The liver can then flush it out of the body, removing it from harm’s way. HDL cholesterol may therefore have a protective effect against heart disease, but only up to a certain point. Too high levels may have the opposite effect and increase heart disease risk. (Keene et al., 2014)

What are the risks of high blood cholesterol levels? 

High cholesterol levels, or more specifically high levels of cholesterol-carrying lipoproteins that contain ApoB on their surface, are a cause of atherosclerosis. Atherosclerosis can lead to the development of coronary heart disease, and increases your risk of having a heart attack or a stroke (Ference et al., 2017). Raised LDL cholesterol levels, total cholesterol levels, and triglyceride levels are all factors that increase your risk of heart disease.

What is atherosclerosis?

Atherosclerosis is where fatty deposits, containing cholesterol and other substances, form plaques within the arteries. Imagine you had water flowing through a pipe, and the pipe suddenly got filled with a large ball of gunk, this would clog the pipe, the same way a plaque clogs up the arteries. 

A key step in this process is the penetration of LDL-cholesterol and apoB-containing lipoproteins into the wall of the artery, causing inflammation (Ference et al., 2017). The resulting plaque restricts blood flow, as it narrows and hardens the artery. Less blood flow means less oxygen reaches the heart muscle which can result in chest pain (angina). When this plaque ruptures, it causes a clot, which actually stops the blood flow and causes a heart attack. 

Poor lifestyle and diet are the main contributing factors to this process. Even when genetics play a role too (people with a family history of heart disease), modifiable lifestyle factors can reduce the risk of atherosclerosis (Khera et al., 2016)

What should my blood cholesterol be?

Ideally, total cholesterol should be below 150 mg/dL, to prevent plaque formation and atherosclerosis. 

Scientists suggest LDL-cholesterol should be around 70 mg/dL or lower. This is the level seen in populations mostly free of heart disease, and where the progression of atherosclerosis in our arteries is halted (O’Keefe et al., 2004)

Medical treatments for high cholesterol

Statins work by reducing how much cholesterol the body produces, and are most commonly prescribed to lower cholesterol. However, the number of people that benefit from this treatment has previously been overestimated in research studies due to bias from the researchers (de Lorgeril, 2010). Statins also have side effects including muscle damage and an increased risk of diabetes (Feingold, 2021).

Ezetimibe is another option, this drug can lower LDL cholesterol levels by 20%, and works by decreasing the absorption of cholesterol and the amount that reaches the liver. Ezetimibe still has side effects, including stomach pain and diarrhea, and these side effects are less common than the side effects with statins (Feingold, 2021).

There’s another option for controlling cholesterol, free from the burden of negative side effects. 

Using food as medicine.

Seeing as diet is the main culprit for raised cholesterol, it’s a perfect solution to bring it down again.

How can food raise my blood cholesterol levels? 

The way our diet affects our cholesterol levels is fully within our control. 

Eating too much trans fat and saturated fat in the diet leads to raised LDL cholesterol in the blood. Saturated fat can cause the body to produce more cholesterol, and reduce the amount that gets broken down and cleared from the body. Dietary cholesterol plays a smaller role in raising blood cholesterol levels but could affect someone with low cholesterol in their diet, if they were to eat a cholesterol-rich meal (Carson et al., 2020)

Other lifestyle factors increase your risk of having high cholesterol. Smoking, for example, damages the blood vessels and makes them more likely to collect fatty deposits containing cholesterol (CDC, 2020)

Type 2 diabetes can also increase levels of small, dense LDL-cholesterol and promote their insertion into the wall of the artery, contributing to atherosclerosis (Vergès, 2009). Type 2 diabetes is also preventable with a plant-based diet. 

Does being overweight affect my chances of having high cholesterol?

Yes, obesity is a known driver for hyperlipidemia, and is associated with increased LDL cholesterol and triglycerides, and overproduction of apoB-containing lipoproteins (Klop, Elte and Cabezas, 2013)

Plant-based diets are associated with lower BMIs and lower weight. Many intervention studies that put people on a plant-based diet have shown it’s highly effective for weight loss, and thus, may reduce the risk of high cholesterol (Remde et al., 2022)

How else can a plant-based diet prevent and reverse high cholesterol?

Keeping LDL cholesterol low is crucial to reduce the risk of atherosclerosis and heart disease. 

There are two ways to do this: live your life taking medication, or center your diet around whole plant foods. As easy as it may seem to take a pill everyday for the rest of your life, there are both side effects, and the actual effectiveness of the drug to contend with (Feingold, 2021). On the other hand, eating a whole-food plant-based diet is both effective and has endless positive side effects.  

What’s the evidence?

A plant-based diet improves lipid profiles by reducing total-, LDL-, and non-HDL-cholesterol levels (Ferdowsian and Barnard, 2009) (Wang et al., 2015)

In one study scientists compared 424 meat-eaters, 425 fish-eaters, 423 vegetarians and 422 vegans, and found vegans had the lowest blood cholesterol levels out of all the dietary patterns. A plant-based diet also reduces levels of apolipoprotein B (Bradbury et al., 2014) (Chiavaroli et al., 2018)

This is a consistent result for plant-based diets. When scientists took the data from 49 different studies they found plant-based diets significantly reduce levels of total cholesterol, LDL cholesterol, and HDL cholesterol (smaller reduction in HDL) compared to omnivorous diets (Yokoyama, Levin and Barnard, 2017)

A plant-based diet has also outperformed a mediterranean diet, another popular healthy dietary pattern, for lowering LDL and total cholesterol (Pagliai et al., 2017) (Rogerson et al., 2018) (Barnard et al., 2022)

How does a plant-based diet lower cholesterol?

  1. Reduced saturated Fat. Plant based diets contain less saturated fat than omnivorous diets because they avoid animal products and processed foods (Bradbury et al., 2014). Meat and dairy are high in saturated fat, which increases LDL cholesterol and apoB concentrations (Chen et al., 2016). Processed foods like fried foods, including those made from plant foods, can also raise cholesterol. Removing these foods from the diet removes most of the saturated fat, and prevents increases in cholesterol. 
  2. Reduced dietary cholesterol. US guidelines no longer set a numerical limit on cholesterol intake, instead they state dietary cholesterol should be as low as possible. This is because saturated fat raises LDL-cholesterol more when dietary cholesterol is also consumed (Siri-Tarino et al., 2010) (Spence, Srichaikul and Jenkins, 2021). Cholesterol is found in animal products - meat, fish, poultry, dairy, and eggs. A single large egg yolk contains 275 mg cholesterol. Given the recommendation for dietary cholesterol was 200 mg/day, it puts into perspective just how much one egg contains! (Spence, Jenkins and Davignon, 2010). Whole plant-foods do not contain cholesterol.
  3. Increase in polyunsaturated fats. Replacing saturated fats with polyunsaturated fats lowers LDL-cholesterol levels further, as well as the subsequent risk of heart disease. They increase the removal of LDL and cholesterol by the liver, reducing the amount circulating in the blood (Mozaffarian, Micha and Wallace, 2010). Plant-based diets contain the highest levels of polyunsaturated fats (Bradbury et al., 2014). Sources include walnuts and flaxseeds. Replacing saturated fat with walnuts has been shown to lower LDL-cholesterol and non-HDL-cholesterol (Tindall, Kris-Etherton and Petersen, 2020).
  4. Increase in plant sterols. Plant-based diets are higher in plant sterols than omnivorous diets (Gylling et al., 2014). Plant sterols are bioactive compounds that can lower, albeit modestly, total and LDL-cholesterol levels. They’re naturally found in vegetable oils, vegetables, fruits, nuts, and legumes, and work by competing with cholesterol for absorption into the intestine, thus reducing the absorption of cholesterol (Mach et al., 2020)
  5. More fiber. An abundance of fiber is one of the best benefits of a plant-based diet. Many plant foods are high in soluble fiber, which can help lower cholesterol levels (Brown et al., 1999) (Mach et al., 2020). Soluble fiber helps to slow down the absorption of cholesterol, and reduce the amount of cholesterol produced by the liver. It also reduces the absorption of fat from the diet. Plant sources of soluble fiber include oats, barley, beans, sweet potatoes, broccoli, and more. Fiber is only found in plants, and sadly most Americans aren’t getting nearly enough fiber in their diets. If you needed another reason to have that big bowl of morning porridge, here it is! 

Takeaway

A whole-food plant-based diet is a great way to manage the risk of high cholesterol. It focuses on the consumption of fruits, vegetables, whole grains, and legumes making it high in fiber and plant sterols to regulate cholesterol. It’s also low in animal products that would otherwise increase cholesterol levels. 

High cholesterol is one of several risk factors for heart disease. It would be an oversimplification to say that cholesterol is the only risk factor for the development of this complex disease. Nonetheless, cholesterol is an important risk factor to manage, which can be achieved with a plant-based diet. You can learn more about plant-based diets and heart disease here.  

Start by removing animal products high in saturated fats, and add some high-fiber foods such as lentils, and beans, which can be made into great plant-based ‘burger’ patties. Adding almost any plant-based food will increase your fiber intake. 

Make sure to also swap those saturated fats for polyunsaturated fats like walnuts and flaxseeds, instead of refined carbohydrates, which is often the easier swap to make. 

Dietary changes can remove or reduce the need for medications - for many this is the end goal, a goal that we at Mora can help you to achieve.

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