Managing Cholesterol - Ask a Nutritionist

March 9, 2023

What's LDL cholesterol? What about HDL cholesterol? They should both be low, right? Understanding cholesterol is an important factor to assessing health risks like developing heart disease or having a heart attack or stroke.  On this week's episode of Ask a Nutritionist Brandy covers some great information on cholesterol including a few ways to lower it without taking any medications.

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Welcome to the “Ask a Nutritionist” podcast, brought to you by Nutritional Weight and Wellness. We are thrilled to have you join us today as we discuss the connection between what you eat and how you feel and share practical real life solutions for healthier living through balanced nutrition. Now, let's get started.

BRANDY: Good morning and welcome to Dishing Up Nutrition’s new midweek segment called “Ask a Nutritionist”. My name is Brandy Buro. I'm a Licensed and Registered Dietitian with Nutritional Weight and Wellness. On today's show, I'll be answering a nutrition question we received from our Dishing Up Nutrition listeners. So today's question: “Can very high or genetic cholesterol be managed with nutrition? I heard you can't out diet, you can't out-fitness, and you can't out supplement this condition.”

So this is a really great question and this is a topic that comes up a lot with my clients in clinic. So first off, why do we really care about cholesterol? Why are we so concerned if we have high cholesterol? Well, cholesterol has been used as a way to assess our risk of developing heart disease or having a heart attack or stroke. And this is a lab test that you probably get checked every time you get a physical.

So it's very routine and you probably know what your numbers are. And if your cholesterol levels come back slightly elevated, you may be recommended to go on a cholesterol lowering medication. That's kind of the traditional way to manage that. And I just want to point out here that we are learning so much more about cholesterol and what some other predictors of someone's risk of developing heart disease are, and we're finding that cholesterol is not actually the best predictor of somebody's risk. There are now more advanced tests that correlate much better with someone's risk.

So we'll talk about what those tests are later in this episode. The conventional thought is that high cholesterol is a concern for heart health. So if somebody has very elevated cholesterol, those cholesterol lowering medications might be recommended. So I think part of that question is, if I have high cholesterol, are there ways to get those numbers in a healthy range through lifestyle? Great question.

What is hypercholesterolemia (genetic high cholesterol)?

So what is this genetic high cholesterol, exactly? Very high cholesterol could be a sign of a genetic disorder called familial hypercholesterolemia. So this is when a person has inherited a genetic mutation resulting in elevated cholesterol, especially a particular type of cholesterol called LDL cholesterol. So with this condition, your body is not able to process that LDL cholesterol and remove it from your body, and that's where that elevated cholesterol comes in.

So it's estimated about half a percent of the population are dealing with this condition. So how do you know if you have this condition: hypercholesterolemia or that genetic disorder? Well, your doctor may diagnose you with this condition if you have elevated cholesterol and you also have close family members like your mom or your dad, or maybe some siblings who have also had high cholesterol or had a heart attack at a very young age, or were diagnosed with heart disease at a relatively young age.

So this is where it gets kind of tricky because high cholesterol and family with high cholesterol may not necessarily mean that you share a genetic mutation. It's possible you're really sharing a similar lifestyle. So what did you inherit? Did you inherit a lifestyle or did you really inherit a genetic disorder? Because that genetic testing is really the only way to be certain that you actually have that genetic mutation. Genetic testing can be very expensive, and some clinics don't offer that type of testing. So some doctors may not actually suggest that test. They may make that diagnosis based on family history and your cholesterol labs. Those cholesterol lowering medications may be recommended based on the assumption you have this condition, but medications come with their own side effects too. So a lot of my clients are coming to me with that question, can I do anything about this while avoiding that medication?

For example, a common side effect of statin drugs, a common cholesterol lowering medication, include muscle aches and joint pain and chronic fatigue. So as you can tell, I mean that's not something we want to live our lives with. So we work on assessing and addressing some of those lifestyle factors that can help lower cholesterol before starting medication. And the good news is it works and there is hope, even if your cholesterol is significantly elevated.

Lifestyle outweighs genetics

And at this point, it's important to remember that lifestyle outweighs genetics. You have a lot more control over your health outcomes than you might think. Genetics and age and your environment account for only about 10% of those health outcomes. 90% of your health outcomes, including your heart health, are related to those lifestyle choices. So if you have high cholesterol or you've been diagnosed with that genetic disorder, familial hypercholesterolemia, there's plenty you can do through lifestyle choices to improve your cholesterol numbers and reduce your risk for heart disease. No matter what your situation is, your body will appreciate you for improving your lifestyle. There's going to be lots of other positive side effects to improving your lifestyle.

Lifestyle factors for managing cholesterol

So what are some of those lifestyle factors that are especially important for managing cholesterol and reducing your risk of heart disease? Well, you know, we're going to talk about food. Our motto is food first, and I'll review some of those nutrition tips in just a moment. But what else do we need to be aware of when it comes to lifestyle? I'd say at the top of the list comes smoking and alcohol use. If you can quit smoking and reduce or eliminate alcohol, that's going to get you very far. Both of those lifestyle choices are risk factors for developing heart disease very clearly, very significantly.

The next one I would look at is sleep. Poor quality sleep and not getting enough sleep are linked to heart disease. So get your sleep. And sleep is definitely a big area for many of our clients. Some people come to us to focus solely on sleep. So nutrition can support you in this area too. Exercise, moving your body is something else you can do to keep your heart strong. Your heart is a muscle. We need to use it to keep it healthy. So moving your body every day 30 minutes is a good kind of of benchmark; great for stress management too, which is another area of lifestyle that's really important when it comes to our heart health. Stress management: chronic stress is very damaging to our heart health. So learning ways to kind of unwind, relax, and try to keep that stress under control, controlling the areas that you can.

Nutrition tips to manage cholesterol numbers

Next we'll talk a little bit more about those nutrition tips to try to help manage your cholesterol numbers the best you can and reduce your risk of heart disease. And we've hosted many podcasts about what to eat to manage cholesterol. We've written a few articles about it too. So if you want to kind of take a deep dive on this topic, I encourage you to go back into those archives and and check out those episodes. But first I want to explain that the primary driver of heart disease is inflammation and insulin resistance.

So these nutrition guidelines are really focusing around reducing inflammation and balancing your blood sugar. If we balance our blood sugar, we can help reduce insulin resistance and we can help reduce inflammation at the same time. Eating real food and avoiding those processed foods as much as possible goes a long way in reducing inflammation. Processed foods and refined sugar and refined carbohydrates will increase insulin resistance and inflammation in the body. Insulin resistance and inflammation will damage arteries. So by eating real food, you're already doing a lot to help your heart.

Avoiding processed carbs and avoiding alcohol is going to reduce something called your triglycerides. So the triglycerides is a simple blood test that accompanies your blood cholesterol test. So if you get your cholesterol test, you will know what your triglycerides are, and triglycerides are a strong independent risk factor for heart disease. If the triglycerides are high, your risk goes up. So just by reducing alcohol consumption and avoiding those processed carbs, you're already reducing your risk of heart disease. Refined oils that you find in processed foods, that you find in deep fried foods, that is something that's going to increase your cholesterol. So getting rid of those foods is going to help drive that cholesterol down, specifically LDL cholesterol that we want to see kept lower.

So we'll remove those refined oils and replace them with real healthy fats. Healthy fats from real foods like avocados, nuts and seeds, olive oil, butter. So these are all protective for our heart, and they're going to help reduce inflammation and reduce damage to our arteries. Another benefit of adding real fat into every meal and snack is that it's going to help stabilize your blood sugar. When we have better blood sugar control, we can slowly help reverse insulin resistance and prevent it from getting worse, which is protective for your heart. So get those good fats in. We also want to make sure we're getting plenty of vegetables and fruits. Fruits and vegetables have antioxidants that help prevent damage to the arteries.

Include omega-3 fatty acids

We also really want to try to add some omega-3 fatty acids. These are essential fats that we only get from food, so we have to be pretty intentional about getting those in. You'll find omega-3 fats in things like salmon and sardines. There's also some in free range eggs and a little bit in walnuts.

So these types of fats can increase your HDL cholesterol. So this is a type of cholesterol that is protective for our heart. We want to see that number a little higher. HDL cholesterol can help reduce inflammation and prevent LDL cholesterol, that type of cholesterol that's more damaging from becoming unstable and damaging our arteries. So these omega-3 fatty acids can be kind of difficult to get in your diet, especially if you're not a fan of fish or you don't have access to that fatty fish all that often.

So if that's the case, I do recommend supplementing with a high quality omega-3 supplement, somewhere between at least 3,000 and 4,000 milligrams every day. So we've just reviewed some key lifestyle aspects of protecting your heart and some key nutrition concepts to be aware of when you're trying to lower your risk for heart disease. So once you make these changes, I suggest tracking your progress by getting those numbers, getting those labs done again, and it can be helpful to have the support of a dietitian throughout this process to help you interpret those results and identify what adjustments you can make to keep making progress.

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Determining heart disease risk

Oftentimes when my clients come to me wanting to lower their cholesterol, they usually come with this goal of my doctor wants me to see him back in his office in a year, and if my cholesterol numbers aren't down, that's when he's going to put me on that medication. So we have this timeframe, you know, what can we do in a year? And I'll often suggest getting those labs checked, you know, six months into it just to see how we're progressing, what's working, what doesn't seem to be working, so we can continually make improvements. Like I said, cholesterol is not the end all be all lab when it comes to assessing your risk for heart disease, but we can still get some valuable information from that, especially when we take a look at the HDL cholesterol and those triglycerides, which we already talked about a little bit.

So that's usually the first thing I look at when I review a client's lab results for their cholesterol levels. For example, one interesting number we can look at is the triglyceride to HDL ratio. This may not be printed in your lab results, but it is very easy to calculate on your own. You simply take your triglyceride number and divide it by your HDL number. This number is a very strong independent risk factor for heart disease. So we look at this number, we want that ratio to be less than one.

Another number that I like to look at that is a better predictor of risk compared to just looking at cholesterol alone is your total cholesterol to your HDL cholesterol ratio. Ideally, this number would be less than 3.5, so that puts you in a low risk category for developing heart disease risk.

Can you see how important that HDL cholesterol is? It is protective for the heart, so we want that HDL to be a little higher so we have more of its protective benefits so we can lower our risk of heart disease. So that's what we can get from the cholesterol panel. Those are some pretty useful numbers to look at, and it's a great way to get a general idea of how you're doing and how some of those lifestyle changes are impacting you.

Available advanced testing for heart health

But if you are somebody that has that diagnosis of familial hypercholesterolemia or your cholesterol was very elevated, maybe it was in the 300s or more, I really encourage you to look at some of the more advanced tests that are available right now. There are several tests that have been shown to be more accurate predictors of heart health and heart disease, or your risk of developing a heart attack or a stroke.

So I'll review a few of those now. One thing you can ask for or request is the total number of LDL particles. The fewer the particles you have, the lower the risk of plaque buildup in your arteries. Another thing you can request is the LDL pattern. So there are different types of LDL cholesterol. Pattern A is the less harmful pattern, and this type of LDL cholesterol is large, more buoyant, it's more resistant to damage compared to the type B pattern. So this type of LDL cholesterol are very small, very dense. They're more likely to damage your arteries. So if you can get that LDL pattern test and get a sense for what type you have, an elevated LDL number is not necessarily as concerning as it might be if you didn't have that information.

Another test you can look for or request is the lipoprotein little A. So this is a type of cholesterol that's responsible for carrying cholesterol to the cells of your arteries, and this is a significant predictor of heart disease risk. We want to keep that level low. So high levels are associated with a higher risk of heart attack or stroke.

So there's one other test that I would suggest you can look into. It's called the coronary artery calcium score. Now this test measures the actual amount of calcified plaque in your arteries. And really that's what we're trying to avoid when we're talking about trying to prevent your risk of a heart attack. So there is a strong correlation with a high coronary artery calcium score and heart disease risk. We want to see this number at zero. This indicates no plaque buildup. The higher the number, the higher the plaque buildup, and the higher your risk of a heart attack or stroke.

Well, I hope this information answers your question and gives you a little more insight about some of the lifestyle factors and food choices that can help you reduce your risk for heart disease. Thank you so much for listening to Dishing Up Nutrition’s “Ask a Nutritionist”. If you have a nutrition question you would like us to answer, we encourage you to join our Dishing Up Nutrition Facebook community by searching Dishing Up Nutrition on Facebook.

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