An integrative nutrition approach to high cholesterol

Photo Cred: Alexander Mils/Pexels

By Kellie Blake, RDN, LD, IFNCP

Cardiovascular disease is the leading cause of death in the United States and, while its development is multifactorial, suboptimal lipid levels can certainly predispose individuals to the disease. However, the standard oversimplified approach of prescribing cholesterol-lowering drugs and recommending the avoidance of cholesterol-containing foods neglects to take into consideration individual risk factors and the vital importance of cholesterol in the body.

Cholesterol is found in every cell membrane functioning to provide durability, but also to impart an impermeable effect. It’s the precursor to all steroid hormones and bile acids, making it vital for the regulation of energy, glucose, and sodium, reproduction and bone homeostasis, and the absorption of dietary fats. When it comes to cardiovascular disease, cholesterol itself is not the enemy. Rather, it’s the type of cholesterol in combination with personalized risk factors that matters.

Low-density lipoprotein (LDL) and other apolipoprotein B (apo B)- containing lipoproteins carry cholesterol throughout the body and are considered offenders in the development of heart disease. As described in the Journal of the American College of Cardiology, LDL, apo-B, and very low-density lipoproteins (VLDL) can cross the endothelial barrier, become caught in the extracellular matrix, and initiate an inflammatory response that leads to degeneration of the arterial wall. As more and more LDL particles become trapped, the formation of large, atherosclerotic plaques occurs increasing the risk of a cardiovascular event.

For years, a low-fat, low-cholesterol diet was recommended for those with high cholesterol. But we now know dietary intake of cholesterol has very little effect on serum cholesterol levels. In fact, the old recommendation to consume less than 300 milligrams of cholesterol per day has been retracted. While the intake of trans and hydrogenated fats can negatively impact blood cholesterol levels, equally important are glucose and insulin.

Elevated insulin and glucose levels are both important to consider as they function in the transcription of lipogenic enzymes. As reported in Current Opinion in Pharmacology, high refined carbohydrate diets encourage the production of triglycerides (TG) in the liver. TG enter the circulation as VLDL, which can then contribute to the inflammatory response and subsequent arterial wall degeneration. In addition, excess refined carbohydrate intake can stimulate adipose tissue to create more fatty acids (FA) that, along with FA from the circulation, become packaged into TG form for storage.

Since traditional cholesterol testing does not take cholesterol particle size into account, when I encounter a patient with elevated total and LDL cholesterol levels, I want to know more. Instead of recommending a one-size-fits-all meal plan, I investigate further to better understand the cholesterol subtype and the underlying factors that could be contributing to the lipid imbalance.

Case Study

Debbie is a 55-year-old female seeking nutrition counseling for high cholesterol. Her physician recommended she try nutrition therapy for three months prior to being placed on a statin. Debbie had been following the Weight Watchers program and said she avoided most dairy products due to bloating. She was eating 50 to 75 percent of her meals out each week and described herself as “lazy” when it came to cooking. She craved chocolate and sweets daily. Debbie had been diagnosed with chronic sinusitis, asthma, kidney stones, and she had gestational diabetes with both of her pregnancies. Debbie said she hated to exercise, she felt her daily stress was overwhelming, and she was not sleeping well. She would get in bed around midnight and scroll social media on her phone before falling asleep around two in the morning.

Debbie was taking prescription medications for anxiety, depression, and allergies, but was also on hormone replacement therapy. Her initial nutritional supplements included vitamins C and D3, calcium, magnesium, zinc, a B complex, and melatonin.

Initial lab work indicated dyslipidemia with total cholesterol of 271mg/dL (recently increased from 236mg/dL), HDL of 59 mg/dL, LDL of 179.8mg/dL (increased from 148.4mg/dL), and triglyceride level of 161mg/dL. Debbie had an optimal vitamin D level of 56ng/mL, but TSH was suboptimal at 3.142 and her fasting glucose was elevated at 102mg/dL with a HgbA1c of 5.4 percent.

In addition to her glucose dysregulation, I suspected declining thyroid function as a contributing factor to her increasing total and LDL cholesterol levels. As reported in Medicine, dyslipidemia is common in both hypothyroidism (HO) and subclinical hypothyroidism (SHO) increasing the risk of cardiovascular disease in these patients. In HO, LDL cholesterol levels often increase related to decreased LDL uptake on the receptors of fibroblasts and hepatocytes. 

In addition, there is a connection between elevated homocysteine levels and LDL cholesterol. A high homocysteine level can induce coronary artery endothelial damage and the oxidation of LDL and increase oxidative stress overall.  

The initial plan for Debbie included:

1. A full elimination diet for a minimum of four weeks, including add 2 tablespoons of olive oil per day to target lipids and metabolic dysfunction; add ½ teaspoon of cinnamon per day to target metabolic dysfunction; and add ½ cup walnuts per day to target metabolic dysfunction
2. Walking for 10 minutes after every meal to target glucose and insulin sensitivity
3. Sleep hygiene techniques, including no blue light for 45 minutes before bed, no food intake within three hours of bed, and be in bed by 10:30 p.m.
4. Meditation to target stress management, including two five-minute sessions per day
5. Nutritional supplements, including omega-3 fatty acid 2,000 milligrams per day to target inflammation and metabolic dysfunction; phosphatidylserine 500 milligrams before bed to target suspected elevated cortisol; thyroid multivitamin once per day; and probiotic once per day to target gut health
6. Additional testing requested: fasting insulin, full thyroid panel including antibodies, homocysteine, ApoA1, ApoB and NMR.

Debbie’s additional lab work confirmed the suspected insulin resistance with LP-IR score of 46, HOMA-IR of 2.46 and fasting insulin level of 9.8 uIu/mL. She was also at high risk of heart disease based on LDL-P of 1592 nmol/L, small LDL-P of 530 nmol/L, APO-B of 118mg/dL, and APOB/APO A1 ratio of .72. Her thyroid antibodies were negative, but free T4 was low at .81mg/dL indicating a sluggish thyroid.

After four weeks on the initial plan Debbie reported the last labs threw her for a loop. Debbie said she had spoken with her doctor about the most recent labs and was given little hope. She said she had increased anxiety and depressive symptoms as she was told her lab work and family history indicated she would likely be placed on a statin drug. I reiterated the power of lifestyle and nutrition to reverse the disease process, but Debbie seemed skeptical.

New goals include a continuation of all previous goals but to eliminate the omega-3 fatty acid supplement and add two targeted supplements: a combination of phytosterols, bergamot, and berberine, and a combination of red yeast rice, CoQ10, and omega-3 fatty acids.  

Increasing phytosterols may be helpful for lowing LDL cholesterol levels. As reported in the Brazilian Journal of Cardiology, the Western diet contains an average of 300 milligrams of phytosterols per day, but increasing to two grams per day may be beneficial when it comes to lowering LDL levels. The polyphenols in bergamot have also been shown to decrease LDL, total cholesterol, and triglyceride levels, and increase HDL cholesterol possibly related to the activation of AMP-activated protein kinase and the inhibition of pancreatic cholesterol ester hydrolase. And berberine, as reported in Nature Medicine, has been shown to reduce LDL and total cholesterol levels as well as triglycerides.

In addition, the monacolins such as monacolin K in the neutraceutical red yeast rice (RYR) can limit the rate-controlling enzyme in the cholesterol synthesis pathway. RYR has been shown to lower LDL, total cholesterol and triglyceride levels while increasing HDL slightly. It also improves endothelial function. CoQ10 supplementation in combination with monacolin K has also been shown in a randomized controlled trial to significantly reduce LDL, total cholesterol, triglycerides, glucose, and blood pressure in patients with metabolic syndrome.

References

Cabral, C. E., & Klein, M. (2017) Phytosterols in the Treatment of Hypercholesterolemia and Prevention of Cardiovascular Diseases. Arquivos brasileiros de cardiologia. Retrieved from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5729784/

Cicero, A., Fogacci, F., & Banach, M. (2019) Red Yeast Rice for Hypercholesterolemia. Methodist DeBakey cardiovascular journal, 15(3), 192–199. Retrieved from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6822657/

Cortes, V. A., Busso, D., Maiz, A., Arteaga, A., Nervi, F., & Rigotti, A. (2014) Physiological and pathological implications of cholesterol. Frontiers in bioscience (Landmark edition). Retrieved from: https://fbscience.com/Landmark/articles/10.2741/4216

Dong, X., Yao, Z., Hu, Y., Yang, N., Gao, X., Xu, Y., & Wang, G. (2016) Potential harmful correlation between homocysteine and low-density lipoprotein cholesterol in patients with hypothyroidism. Medicine. Retrieved from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5265788/

Ference, B. (2018) Impact of Lipids on Cardiovascular Health: JACC Health Promotion Series. Journal of the American College of Cardiology. Retrieved from: https://www.sciencedirect.com/science/article/pii/S0735109718353798

Kong, W. (2004) Berberine is a novel cholesterol-lowering drug working through a unique mechanism distinct from statins. Nature medicine. Retrieved from: https://pubmed.ncbi.nlm.nih.gov/15531889/

Mazza, A. (2018) Effect of Monacolin K and COQ10 supplementation in hypertensive and hypercholesterolemic subjects with metabolic syndrome. Biomedicine & pharmacotherapy = Biomedecine & pharmacotherapie. Retrieved from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6361161/

Nauman, M. C., & Johnson, J. J. (2019) Clinical application of bergamot (Citrus bergamia) for reducing high cholesterol and cardiovascular disease markers. Integrative food, nutrition and metabolism. Retrieved from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6497409/

Wong, R. H., & Sul, H. S. (2010) Insulin signaling in fatty acid and fat synthesis: a transcriptional perspective. Current opinion in pharmacology.  Retrieved from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3092640/