Mr. N., a retired 61-year-old teacher, had been on atorvastatin for eight months, but his cholesterol remained elevated at 8.32, triglyceride 5.31, HDL 1.15, LDL 5.26. His blood pressure was 140/100, and he was modestly overweight.

I prescribed ezetimibe 10 mg a day, and he returned with cholesterol of 5.41, triglyceride 0.91, HDL 1.38, LDL 3.61. BP was now normal, and he’d lost close to 8 kg. But there’s a catch — he’d never started the ezetimibe! Instead, he’d made lifestyle changes, and began taking garlic and omega-3 supplements.

Both the patient and physician are ec- static about these results. Most patients that I ask to lose five pounds gain 10.

What made the biggest difference in Mr. Natural was significant weight loss and a healthy diet, rich in vegetables and fibre.

Garlic has achieved inconsistent results. The most recent high-quality trial suggests that garlic has minimal impact on hypercholesterolemia.

Fatty fish
Omega-3 fatty acids are vascular-protec- tive, but don’t act through a lipid effect. I currently recommend that my patients consume fatty fish three to five times a week, or omega-3 fatty acids if they prefer, DHA +EPA 3 g a day.

Fifteen grams of fish oils a day can lower triglycerides up to 50%. That’s a lot of capsules, so it’s far better to eat fatty fish if they enjoy it.

Initial excitement about soy has faded as the most recent studies find that even 50 g per day of soy protein lowers LDL cholesterol by just 3%. The supple- ments policosanol, extracted from cane sugar wax, and Guggulipid, a tree resin extract, have shown no clear benefit and can’t yet be recommended.

Sterols are the plant world’s equiva- lents of cholesterol. Supplementing foods with plant sterols causes choles- terol malabsorption and leads to reduc- tion in LDL cholesterol of around 10%.

Eat your fibre
Soluble fibre, especially psyllium, is a proven cholesterol-buster. Red rice is a statin in disguise, its active ingredient being a metabolite of lovastatin. Nuts are a good addition if taken in modera- tion. Small trials show that walnuts and almonds are rich in healthier fats.

For most people, a Mediterranean diet rich in fruits, vegetables, whole grains, beans, nuts and seeds including healthy fats, and fish is best. For vegetarians, Dr. David Jenkins, professor in nutri- tional sciences at Toronto University and a regular contributor to Parkhurst Exchange, has pioneered the portfolio diet, combining plant sterols, soy protein, high fibre, vegetables and almonds. It has demonstrated LDL reduction near 30%. While this diet isn’t for everyone, it’s another option.