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.
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.
Gregory P. Curnew, MD, FRCPC is Associate Professor at McMaster University in Hamilton, ON, and Director of the Coronary Care Unit at Hamilton General Hospital.
Andrew Dick is a medical student at McMaster University.