By John Messmer, MD

When we think of lowering cholesterol, usually that means eating less fat. An exception to the rule is plant sterols and stanols--fats that can lower cholesterol.

The Basics on Sterols and Stanols

Sterols are building blocks for cells: The basic structural unit of living organisms. Cholesterol is the sterol found in animals. In addition to cells, it is converted into hormones and into bile which we use to absorb fats. We absorb about half the cholesterol we consume and that amount accounts for only a small portion of the cholesterol in our blood. Most of our blood cholesterol is made in our livers.

The cells of plants have sterols, too; mostly sitosterol and sitostanol, but there are others. A stanol is a sterol that is saturated; like a saturated fat. When we eat plants, we absorb the sterols and stanols. In fact, in the intestine, plant sterols and animal sterols are absorbed by the same mechanism. The more plant sterols in our food, the more we absorb instead of cholesterol. Absorbing less cholesterol leads to lower blood levels.

Here’s the catch: there is so little of the various sterols in most plants that we cannot eat enough, even if we are vegetarians, to significantly lower our blood cholesterol level. So, scientists have developed a way to extract the sterols from plants and convert them into a more absorbable form that can be added to other foods already high in fat so that we may consume enough to get an effect.

Sterol-Fortified Foods

For several years, sterol-fortified margarines, marketed to assist in reducing cholesterol, have been available. About 2-3 grams of plant sterols a day can reduce cholesterol about 10-15%. Two to three tablespoons of these margarines provide the necessary amount of sterols.

In recent years, plant sterols have been added to other high-fat foods, including chocolate candy (CocoaVia®), yogurt, cheese, bread, and granola bars. High-fat foods can deliver more sterols per ounce because the fatty sterols are just part of the regular fat content. One brand of orange juice has sterols added, but to get the amount of sterols in two tablespoons of cholesterol-lowering margarine, you would have to drink more than a quart of juice.

Sterol-Fortified Foods and the Impact on Your Cholesterol Levels

Are plant sterols powerful enough to lower cholesterol without using drugs? The answer is, unfortunately, probably not for most people with high cholesterol. Someone with an LDL (or “bad” cholesterol) of 160 whose goal is an LDL of 100 requires a 38% reduction in LDL, so plant sterols are not enough. However, they can provide additive effects to prescription medications. Many physicians think that even people with no history of heart disease and relatively normal cholesterol levels could reduce their risk of atherosclerosis if their cholesterol is even a little lower. The benefit, if any, of using plant sterols would be small, but since we often do not realize our actual risk of atherosclerosis until it develops, it seems reasonable to use these sterol-fortified foods even with normal cholesterol levels. However, long-term studies on the health benefits in those with normal cholesterol have not been completed at this time.

There is a rare genetic condition, homozygous sitosterolemia, that might be worsened by high sterol content foods, but that is controversial. There are no studies proving safety of these foods in children or pregnant women. Hypothetically, large amounts of plant sterols could reduce the amount of fat soluble vitamins absorbed, but there is no consensus on that yet.

Foods that contain large amounts of plant sterols and stanols include sesame seeds (about 700 mg per 3 oz. serving), wheat germ (about 400 mg per 3 oz.), and peanuts (about 220 mg per 3 oz. serving). Most other vegetables and seeds have far less. Even a vegetarian is unlikely to consume more than one gram of plant sterols and stanols in a day – less than half the 2-3 grams required to lower cholesterol. Additionally, the sterols are not easily absorbed until they are changed or esterified for better absorption as they are in sterol-fortified foods.

Conclusion

People with high cholesterol should not undertake the use of plant sterol-fortified foods to reduce their cholesterol levels without consulting their physicians to be certain they are reaching their cholesterol goals. Most will still need a prescription medication, but plant sterols can help as part of a comprehensive plan that includes a proper diet and exercise regimen.

References

1. http://www.ific.org/publications/factsheets/sterolfs.cfm. Accessed 30 November 2007.

2. Plat J., Mensink RP. Plant stanol and sterol esters in the control of blood cholesterol levels: mechanism and safety aspects. Am. J. Cardiol. 2005 Jul 4;96(1A):15D-22D.

3. Lichtenstein, AH, et al. Stanol/Sterol Ester-containing foods and blood cholesterol levels. Circulation. 2001;103:1177.

4. Katan MB, et al. Efficacy and safety of plant stanols and sterols in the management of blood cholesterol levels. Mayo Clin. Proc. 2003 Aug;78(8):965-78.

5. http://www.benecol.net/healthcareprofessionals.asp?viewID=2369# . Accessed 1 December 2007.

6. http://www.clevelandclinic.org/heartcenter/pub/women/sterolstanol.htm

By Megan Porter, RD/LD

You can help trim your waist and get better blood sugar and blood cholesterol results by trimming the size and the fat off your meat.

Limit Saturated Fats and Cholesterol

The four major kinds of fats in the foods we eat are saturated, polyunsaturated, monounsaturated, and trans fatty acids. Both saturated fats and trans fats raise blood cholesterol, as may dietary cholesterol, which is found in foods from animal origin. Having a high level of cholesterol in your blood becomes a major risk factor for coronary heart disease, which can lead to a heart attack, and/or stroke.

Saturated fat has also been linked to increasing your insulin resistance, meaning your body is not using insulin like it should, resulting in higher blood sugar values. One way to decrease your insulin resistance and total blood cholesterol level is by limiting foods high in saturated fat and/or cholesterol, such as fatty meats.

Eating Less and Lean

The American Diabetes Association recommends that you should aim for no more than 7% of your calories from saturated fat. For a person consuming 1800 calories per day this would mean 14 grams of saturated fat per day. It is also recommended that you restrict your intake of dietary cholesterol to no more than 200mg/day.

While counting your daily allowance of saturated fat and cholesterol, remember that meat is not your only source of these fats. You find saturated fat and cholesterol in such foods as eggs, cheese, yogurt, as well as meats.

Shop Lean

Your first defense to keeping within your target levels for saturated fat and cholesterol is while shopping for meat and other products. I encourage you to choose cuts of meat that are lower in fat (i.e., round, sirloin, chuck, loin or tenderloin, and loin chop). Purchase the "choice" grade of meat which is usually lower in fat than "select" and skip "prime," which is usually highest in fat. Add lean choices of poultry to your basket. It is a lower-fat selection than red meats, thus making them lower in calories as well—especially if you leave the skin on your plate and choose the white meat over the dark. Additionally, when selecting ground meats, choose lean or extra lean (no more than 10% fat) to save on fat and calories. Use these meats for no more than two-to-three meals per week.

Don’t Forget the Fish and Legumes

Next, head over to the fish aisle and select any non-fried fish or shellfish (limit shrimp which is high in cholesterol) for at least two meals per week. These are naturally low in saturated fats and have high amounts of the healthy mono- and poly-unsaturated fats that can aid in raising the “healthy” HDL cholesterol levels in your blood. Fish has also been shown to decrease the risk of heart disease.

Then for the remaining two meals, choose legumes such as black beans, garbanzo beans, kidney beans, black-eyed peas, etc. for a meatless meal that is absent of cholesterol (because legumes are not of animal origin) and which have a trace amount of saturated fat.

Look It Over, Then Trim

When preparing your meat prior to cooking, always trim away any visible fat before cooking. Prepare your meats by baking, broiling, roasting, microwaving or stir-frying. Do not fry your meat because frying adds unnecessary additional fat. When cooking the “choice” grade of meats, or leaner cuts of meats, you may need to use a cooking method that either retains the moisture or adds in moisture such as roasting or using a slow cooker.

One Serving Is Equal to a Deck of Cards

When serving yourself meat, remember that by keeping your meat and your portion size trim, you’ll keep trim yourself. Choosing meat in small amounts can be part of a healthy diabetes meal plan. A serving size is 4 ounces of raw meat, or 2 to 3 ounces of cooked meat, which is about the size of a deck of cards or a woman's palm. The American Heart Association recommends no more than 6oz of cooked lean meat per day.

Before eating, look on your plate. The portion of your meat, fish, or shellfish should cover no more than a quarter of your 9-inch plate.

Watch Your Intake: Decrease Your Risk

Eating meat is not going to directly raise your blood sugar levels, but it may be a culprit of high intakes of saturated fat, cholesterol, and calories; therefore, it can indirectly increase your blood sugar levels and your risk for heart disease. So watch your intake, and decrease your risk for heart disease.

Source: By The American Diabetes Association (ADA) “2006 medical nutrition therapy guidelines for diabetes prevention”, Diabetes Care 29:S4-S42, 2006.

By Krista Scott-Dixon, PhD

With an aging population and rising rates of cardiovascular diseases such as heart attack and stroke, most people in North America have at least some inkling of what cholesterol is, and that high cholesterol is bad for their heart health. However, few people know what cholesterol is, what it does, or what role it plays. This recently released report from the Johns Hopkins School of Medicine provides a 7-point, easy-to-understand guide to cholesterol and its role in disease.

Here are the 7 elements:

1.   Know your target cholesterol levels

This section explains what cholesterol is and what it does in the body. Cholesterol is made by the liver (although we can also eat cholesterol in our food) and does a number of important things in the body. For example, it helps the body make particular hormones such as estrogen, and is an important part of the membranes that encase the body's cells.

Cholesterol cannot get to where it needs to be on its own, so it hitches a little ride on 3 types of lipoproteins:

• Very-low-density lipoprotein (VLDL)
• Low-density lipoprotein (LDL)
• High-density lipoprotein (HDL).

In fact, when we talk about cholesterol levels, we are actually talking about measuring levels of these lipoproteins. HDL, often known as good cholesterol, is seen as beneficial because it tidies up cholesterol as it goes, returning it to the liver. LDL, often known as bad cholesterol, can be a problem because it can accumulate and help form plaque on artery walls.

Like a hallway cluttered with junk, this buildup can then impede blood flow to the heart by narrowing the arteries or enabling the creation of a blood clot, both of which are bad news for the heart. The report provides a chart of what things you should test to check your cholesterol and blood lipid levels, and what the ideal values are.

2.   Focus on the right fats

Dietary fats have gotten a bad rap in recent years, and people assume that cutting out all dietary fat will make them healthier. In fact, says the report, it is the type of fat in the diet that is important. Saturated fats and processed trans fats should be avoided, while mono- and poly-unsaturated fats, particularly omega-3 fatty acids such as fish oil, should make up a moderate dietary fat intake.

3.   Make the most of cholesterol-busting foods

This includes foods rich in fiber, good fats, plant sterols and stanols, and (with some hesitation) soy products.

4.   Reduce cholesterol with medication

This section explains how the standard cholesterol-lowering medications work, how to take them, and how to choose one that might be right for you.

5.   Consider combo therapy to reduce cholesterol

Combining particular medications and supplements (for example, niacin, vitamin B3, and statin drugs) both enhance the overall effect as well as lower the risk of potentially serious side effects.

6.   Boost your HDL - for multiple benefits

As one character yells at a concert in the mockumentary film FUBAR, "Turn up the good! Turn down the suck!" Much of the report focuses on lowering the bad cholesterol, but let's not forget bringing up levels of the good cholesterol.

7.   Remember your ABCs

This is a handy checklist for strategies that can help prevent heart attacks:

1. • Aspirin - low doses daily, if appropriate
   • Blood pressure - keep it below 120/80 if possible
   • Cholesterol - keep the bad stuff down, keep the good stuff high
   • Diet and weight control
   • Exercise.

Overall, this is a nice, comprehensible report that is accessible to most readers and a handy reference guide for trips to the doctor in case you can't remember the difference between your 130mm Hg and your 130mg/dL.

As a lifestyle and fitness educator, however, I feel slightly uncomfortable with the report's overt focus on medication as a primary solution. While the report makes some excellent nutritional suggestions (particularly about fat intake), and notes that "lifestyle measures can have a greater impact on preventing coronary heart disease and heart attacks than on practically any other disorder" (7), it does seem to imply that people concerned about cholesterol should make medication a central part of their treatment. For example, it suggests that "as many as 36 million people [in the United States] should be taking cholesterol-lowering medications. Yet only 12 to 15 million of them are currently taking such medication, and many (probably most) are taking too small a dose." (1)

In this vein (pardon the pun), the report outlines a wide range of medication options. Although informative, it may leave the reader with the impression that one has to consume a handful of pills to keep heart-healthy. Given the massive subsidization of medical research by pharmaceutical companies, it is a good idea for consumers to be as critical as possible and ask lots of pointed questions about how and why they should (or shouldn't) be taking medications.

Moreover, given that many of these medications may be taken long-term, patients (particularly those whose immediate risk is not dire) should also investigate a variety of options before committing to the cost and physical impact of taking drugs every day. Side-effects of statin drugs, while rare, can be severe and include:

• Myopathy - chronic muscle diseases or more mildly, muscle pain and fatigue
• Rhabdomyelosis - a potentially fatal condition in which the body isn't able to properly clear the waste products of muscular activity
• Myoglobinuria and Acute renal necrosis - kidney damage and death (Moosman and Behl 2004).

One medication (cerivastatin, aka Baycol), was voluntarily removed from sale in the United States in August of 2001 after severe occurrences of these types of side-effects among users, including approximately 100 reported deaths linked to the drug's use (Pasternak et al 2002).

Some research has also questioned whether there is even a direct link between treating cholesterol levels and lowering the risk of heart attack—in other words, will keeping your bad cholesterol levels down through drugs ultimately prevent you from keeling over? (Ravnskov 2002) Certainly, it never hurts to be curious and skeptical when considering a long term medication regimen.

While the report alludes to fruit and vegetable intake, it does not mention much about the role of antioxidants. Emerging data suggests that antioxidants, when consumed in food format (rather than as supplements, as some disappointing studies on beta-carotene, vitamin C, and vitamin E have shown), can help lower bad cholesterol and elevate good cholesterol.

Antioxidants, along with omega-3 fatty acids, may also play an important role in controlling the inflammation that helps enable arterial plaques and other chronic conditions. Antioxidants are found in colorful fruits and vegetables (such as dark leafy greens and citrus fruits) along with other sources such as red wine, green and black tea, and cocoa—good news for those of us who love a little dark chocolate and the occasional shiraz! Although the contribution of dietary antioxidants to a cholesterol treatment plan can be modest, it should not be under-emphasized in a multi-factor therapy approach.

Nevertheless, the report certainly reminds readers that lifestyle changes are important. Regular activity and good nutrition have effects that go far beyond symptomatic cholesterol levels, which is why it is essential to include them in any wellness program. Many of these changes are relatively easy for most people to understand and do. This includes:

• Quit smoking (OK, well, at least this one is easy to understand)
• Increase regular physical activity
• Lose weight
• Improve the quality of your diet
• Drink alcohol in moderation.

The medication component (considering appropriate, targeted drug therapy) is slightly more complicated. People should be encouraged to ask lots of difficult and probing questions of their doctor. Do I need this? Why? How long do I have to take this? What other things can I do? While the average person can't be a medical expert, they can certainly make like a 3-year-old, ask lots of "why" and "how" questions, and not stop until they feel confident that all of their inquiries have been answered.

One element I would also liked to have seen in this report is stress reduction. Research suggests that mental and emotional stress, such as depression and anxiety, can actually have notable effects on blood cholesterol and overall cardiovascular health (for example, Bachen et al 2002).

The report focuses on reducing cholesterol, and so its suggestions are aimed at controlling levels once they become a problem. However, as always, prevention is the best medicine. Keeping cholesterol and other things like blood pressure in a healthy range is a lot easier than bringing it down once it is out of control.