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people are beginning to learn about and take the proper precautions to prevent and treat heart problems. Keeping cholesterol levels in the safest range (between 180 and 200 mg/dL) is one way of statistically reducing your risk of suffering a heart attack or stroke. Types of Cholesterol, and the Impact on Your Health Low Density Lipoprotein (LDL) Low density lipoprotein (LDL) is called the "bad" form of cholesterol. LDL carries most of the cholesterol in the blood, and the cholesterol from LDLs is the main source of damaging accumulation and blockage in the arteries. Thus, the more LDLcholesterol you have in your blood, the greater your risk of disease. If you have coronary heart disease (CHD) and your LDL is higher than 100 mg/dL, your cholesterol may well be too high for you. High Density Lipoprotein (HDL) High density lipoprotein (HDL) is called the "good" form of cholesterol. HDL picks up and transports cholesterol in the blood back to the liver, which leads to its elimination from the body. HDL can help keep LDL cholesterol from building up in the walls of the arteries. If your level of HDL cholesterol is below 35 mg/dL, you are at substantially higher risk for CHD. The higher your HDL cholesterol level, the better. The average HDL-cholesterol for men is about 45 mg/dL, and for women it is about 55 mg/dL. Triglycerides Triglycerides are a form of fat carried through the bloodstream. Most of your body's fat is in the form of triglycerides stored in fat tissue. Only a small portion of your triglycerides are found in the bloodstream. High blood triglyceride levels alone do not cause atherosclerosis. But lipoproteins that are rich in triglycerides also contain cholesterol, which causes atherosclerosis in many people with high triglycerides. So high triglycerides may be a sign of a lipoprotein problem that contributes to CHD. Serum (blood) cholesterol levels are affected not only by what you eat, but also by how quickly your body creates LDL cholesterol and eliminates it. Most people manufacture all the cholesterol they need in their liver, and it is not necessary to obtain any surplus cholesterol from food. Patients with coronary artery disease typically have too high a level of LDL cholesterol in their blood. Multiple factors help determine whether your LDL cholesterol level is high or low. The factors discussed next are the most important: The following factors are the most important: Heredity Your genes control how high your LDL cholesterol is by affecting how fast LDL is made and removed from the blood. One specific form of inherited high cholesterol is familial hypercholesterolemia, which often leads to early CHD. Even if you do not have a specific genetic form of high cholesterol, genes play a role in affecting your LDL cholesterol level. What you eat Saturated fat, found mostly in foods that come from animals, increases your LDL cholesterol level more than anything else in your diet. Dietary cholesterol also plays a part. The average American man consumes about 360 mg of cholesterol a day; the average woman, between 220 and 260 mg. Eating too much saturated fat and cholesterol-rich foods such as eggs is the main reason for high levels of cholesterol and a high rate of heart attacks in the United States according to the Centers for Disease Control. Reducing the amount of saturated fat and cholesterol you eat is a very significant step in reducing blood cholesterol levels. Here are the 1999 dietary recommendations from the American Heart Association: "Cholesterol is found in meat, poultry, seafood and dairy products. Foods from plants-such as fruits, vegetables, vegetable oils, grains, cereals, nuts, and seeds-don't contain cholesterol. Egg yolks and organ meats are high in cholesterol. Shrimp and crayfish are somewhat high in cholesterol. Chicken, turkey, and fish contain about the same amount of cholesterol as do lean beef, lamb and pork." As can be seen from the above recommendations, it is hard to avoid consuming foods that cause cholesterol to build up in the blood. Weight Excess weight tends to increase LDL cholesterol level. If you are overweight and have a high LDL cholesterol level, losing weight may help lower it. Weight loss also helps to lower triglycerides and raise HDL. Conversely, it is now accepted that even small increases in weight may increase cholesterol and the general risk of cardiovascular disease. Physical activity/exercise Frequent physical activity may lower LDLcholesterol and raise HDL-cholesterol levels. Age and sex Before menopause, women usually have total cholesterol levels that are lower than those of men the same age. As women and men get older, their blood cholesterol levels rise until about 60 to 65 years of age. In women, menopause often causes an increase in LDL cholesterol and a decrease in HDL cholesterol level, and after the age of 50, women often have higher total cholesterol levels than men of the same age. Alcohol Alcohol intake increases HDL cholesterol but does not lower LDL cholesterol. Drinking too much alcohol can damage the liver and heart muscle, lead to high blood pressure, and raise triglycerides. Because of the risks, doctors don't recommend alcoholic beverages as a way to prevent CHD, yet the consumption of just one glass of red wine or other alcoholic beverage statistically reduces the risk of heart attack and stroke without causing other health problems for most people. Stress Stress over the long term has been shown in several studies to raise blood cholesterol levels. One way that stress may do this is by affecting your habits. For example, when some people are under stress, they console themselves by eating fatty foods. The saturated fat and cholesterol in these foods contribute to higher levels of blood cholesterol. Who's at Risk? "At risk" cholesterol numbers are considered to be anything above 200 mg/dL for total serum cholesterol with the caveat that the dangerous LDL cholesterol (low density lipoprotein) number be less than 100 mg/dL. HDL cholesterol (high density lipoprotein), the aptly named "good" cholesterol, can be increased using specific nutrient supplements and by limiting total serum cholesterol intake. If your HDL is less than 35 mg/dL, your physician will try to help you increase it, while lowering LDL cholesterol. Here's a fact for you to consider! A person with a total serum cholesterol number of 260 mg/dL increases his or her chance of a heart attack by 500% (Annals of Internal Medicine (United States), 1979). Cholesterol is a vital substance that is synthesized by the liver and other bodily tissues. The body uses cholesterol as a building block for essential organic molecules such as steroid hormones, cell membranes, and bile acids. Our bodies produce between 500 to 1000 mg total serum cholesterol each day, and this amount is added to the typical American's diet, which may contain an additional 500 to 1000 mg a day of additional cholesterol-half of which is absorbed into the body. Therefore, the total elimination of all cholesterol from dietary sources may not be enough for some people, and over time they may face elevated cholesterol levels and require additional measures to control or reduce cholesterol (Heart Disease, Preventive Medicine, 1992). Source of risk factors: Columbia and Boston Universities, 1999. Cholesterol and the Threat of Unstable Plaque Cholesterol is a major ingredient of the plaque that collects in the coronary arteries and causes CHD, so it is important to understand how plaques develop. Excess cholesterol is deposited in the artery walls as it travels through the bloodstream. Then special cells in the artery wall gobble up this excess cholesterol, creating a "lump" in the artery wall. This cholesterol-rich "lump" then is covered by a scar that produces a hard coat or shell over the cholesterol and cell mixture. It is this collection of cholesterol covered by a scar that is called plaque. The plaque buildup narrows the space in the coronary arteries through which blood can flow, decreasing the supply of oxygen and nutrients to the heart. If not enough oxygen-carrying blood can pass through the narrowed arteries to reach the heart muscle, the heart may respond with a pain called angina. The pain usually happens with exercise when the heart needs more oxygen. It is typically felt in the chest or sometimes in other places like the left arm and shoulder. However, this same inadequate blood supply may cause no symptoms. Cardiovascular disease is often a "silent" disease, until something happens. Plaques come in various sizes and shapes. Throughout the coronary arteries many small plaques build themselves into the walls of the arteries, blocking less than half of the artery opening. These small plaques are often invisible on many of the tests doctors use to identify coronary heart disease. It used to be thought that the most dangerous plaques and the ones most likely to cause total blockage of coronary arteries were the largest ones. The largest plaques are in fact the ones most likely to cause angina. However, small plaques that are full of cholesterol but not completely covered by scar are now thought to be very unstable and more likely to rupture or burst, releasing their cholesterol contents into the bloodstream. When this happens, it precipitates blood clotting inside the artery. If the blood clot totally blocks the artery, it reduces or stops blood flow, and a heart attack occurs. The muscle on the far side of the blood clot does not get enough oxygen and begins to die. The damage can be permanent. Lowering your blood cholesterol level can slow, stop, or even reverse the buildup of plaque. Cholesterol lowering can reduce your risk of a heart attack by lowering the cholesterol content in unstable plaques to make them more stable and less prone to rupture. This is why lowering your LDL cholesterol is such an important way to reduce your risk for having a heart attack. Even in people who have had one heart attack, the chances of having future attacks can be substantially reduced by cholesterol reduction. One of the best methods of reducing cholesterol is through dietary modification (see Dash Diet in Hypertension protocol). Supplements offer excellent synergistic benefits to augment dietary measures. The Benefits of Lowering Cholesterol A 5-year clinical trial with over 4400 patients with heart disease found that lowering cholesterol can prevent heart attacks and reduce death in men and women who already have heart disease and high cholesterol. Researchers say that the following benefits could be expected if physicians were to treat their heart disease patients for the same 5-year period and lower cholesterol to the same extent. For every 1000 patients, Forty people would be saved out of the 90 who would otherwise die from heart disease. Seventy of the expected 210 nonfatal heart attacks would be avoided. Heart procedures such as bypass surgery would be avoided in 60 of the 210 patients who would be expected to need these procedures. The most recent report of the National Cholesterol Education Program identified low HDL cholesterol as a coronary artery disease risk factor and recommended that "all healthy adults be screened for both total cholesterol and HDL cholesterol levels" (Am. J. Cardiol., Nov. 1998, 82:9A, 13Q-21Q). Landmark clinical studies in the past several years have demonstrated diminished mortality and first coronary events following lowering of low density lipoprotein (LDL) cholesterol. The Framingham Heart Study (a long-term research study) produced compelling evidence indicating that a low level of HDL cholesterol was an independent "predictor" of coronary artery disease (CAD). Many community health organizations, local drug stores, and health food stores regularly provide low-cost or free cholesterol screening for those interested in monitoring their serum cholesterol. Seek the advice of a competent physician experienced in cholesterol management using dietary modification and nutritional supplements. A physician with this kind of background can also help with the substitution of nutrient-based cholesterol-reduction plans which may allow the reduction or elimination of prescription drugs. If you already have high blood pressure as well as high blood cholesterol (and many people do), your physician may also tell you to cut down on sodium or salt. As long as you are working on getting your blood cholesterol number down, this is a good time to work on your blood pressure, too. Traditional Therapies HMG CoA Reductase Inhibitors. Drugs that inhibit the enzyme HMG-CoA reductase are referred to as "statins." These drugs lower cholesterol by slowing down the production of cholesterol and by increasing the liver's ability to remove the LDL cholesterol already in the blood. The latest introduction to the powerful group of lipid-lowering drugs known as statins, or HMG reductase inhibitors, is atorvastatin (Lipitor). It is the only statin approved for the reduction of triglycerides as well as total and LDL cholesterol. It reduces LDL by 40 to 60%, triglycerides by 20 to 40%, and raises HDL cholesterol by 5 to 10%, changes which may be bigger than those produced by other statins. It can be taken once a day, at any time of day, and the recommended dose range is from 10 to 80 mg a day. Atorvastatin provides the lowest cost per percentage of LDL cholesterol reduction of available statins. Other available statins which primarily reduce LDL cholesterols are cerivastatin (Baychol), fluvastatin (Lescol), lovastatin (Mevacor), pravastatin (Pravachol), and simvastatin (Zocor). Additional drugs that are commonly prescribed and approved for lowering elevated triglyceride levels are gemfibrozil and clofibrate. These drugs may be prescribed alone or in combination with other drugs. These triglyceride-lowering drugs have toxic side effects that cause many people to avoid them. Integrated and Alternative Medical Approaches Some people with high cholesterol are able to reduce to safe levels by using combinations of dietary supplements that have been shown to lower serum cholesterol, protect against LDL cholesterol oxidation, and reduce the risk of an abnormal arterial blood clot formation. Benefits of Curcumin Curcumin, also known as turmeric root, an ancient spice in the ginger family, is gaining attention for its positive impact on a number of diseases, including cholesterol reduction. Scientific evidence has been building since the mid-1980s of curcumin's potential cholesterol-lowering capabilities. For example, animals fed small doses of curcumin had their cholesterol levels drop by one half (50%) over those that did not receive curcumin. Curcumin reduces cholesterol by interfering with intestinal cholesterol uptake, increasing the conversion of cholesterol into bile acids, and increasing the excretion of bile acids, according to the International Journal of Vitamin Nutritional Research (1991, 61:364-69). The 1992 Indian Journal of Physiology reported that ten human volunteers taking curcumin showed a 29% increase in beneficial HDL cholesterol in only 7 days. Total cholesterol also fell 11.6% and lipid peroxidation was reduced by 33%. In January of 1997, the Journal of Molecular Cell Biochemistry reported curcumin has demonstrated, in vivo, the ability to decrease total cholesterol and LDL cholesterol levels in serum and to increase the beneficial HDL cholesterol. "Blood cholesterol was lowered significantly by dietary curcumin in these diabetic animals. Significant decrease in blood triglyceride and phospholipids was also brought about by dietary curcumin in diabetic rats." The research has continued and curcumin's ability to lower blood cholesterol levels was reported in the April 1998 issue of Molecular Cell Biochemistry, and again, later that year, researchers in Biofactors (1998, 8:1-2, 51-57) reported that "curcumin extract may be protective in preventing lipoperoxidation of subcellular membranes." Curcumin also provides an additional benefit by potentially reducing the risk of cardiovascular-related disease as it inhibits platelet aggregation and significantly decreases the level of lipid (LDL) peroxidation. "Observation of curcumin's mechanism of action shows that it blocks the formation of thromboxane A2, a promoter of platelet aggregation, thereby inhibiting abnormal blood clot formation. Curcumin also increases a prostacyclin, a natural inhibitor of platelet aggregation" (Arzneim. Forsch., 1986, 36:715-17). Benefits of Gugulipid (Commiphora mukul) This powerful ancient remedy has been re-discovered by Western culture. Gugulipid is made from the resin of the commiphora mukul tree of north central India. Gugulipid (gugulesterones) has been used for thousands of years to alleviate problems associated with obesity, acne, viral infections, and other ailments. In a study published in 1989 by the Journal of Associated Physicians-India, 125 patients receiving gugulipid showed an 11% decrease in total serum cholesterol, a drop of 16.8% in triglycerides, and a 60% increase in HDL cholesterol within 3 to 4 weeks. Patients with elevated cholesterol levels showed much greater improvement than normal patients. The study quoted a second trial (included in the article noted above) where 205 patients receiving gugulipid at a dose rate of 25 mg administered 3 times daily showed a 70 to 80% reduction of serum cholesterol, whereas no response was found in the placebo group (Journal of Associated Physicians-India, 1989, 37[5]:328). A placebo-controlled trial of 40 patients with high blood-fat levels showed a serum cholesterol reduction of 21.75%, with triglycerides being reduced by 27.1% in only 3 weeks, and after continuing the study for 16 weeks it was learned that HDL cholesterol was increased by 35.8% (Journal of Associated Physicians-India, 1989, 37[5]:328). Benefits of Garlic A study published in the Journal Nutrition Research (1987, 7:139-49) showed that a liquid garlic extract made by Kyolic caused a 12 to 31% reduction in cholesterol levels in the majority of test subjects after 6 months. The study showed that 73% of the subjects given the Kyolic garlic experienced a greater than 10% reduction in cholesterol, compared with only 17% of the subjects in the placebo group showing the same improvement. If you have high LDL cholesterol levels, garlic supplementation is especially important because LDL cholesterol oxidation causes atherosclerosis, and garlic specifically inhibits LDL oxidation. And garlic helps protect the arterial lining against oxidation. Most importantly, garlic prevents abnormal platelet aggregation (thrombosis) via several different mechanisms. The formation of arterial blood clots is the primary cause of most heart attacks and strokes. Investigators reported in a study published in the American Journal of Clinical Nutrition (1996, 64:866-70) that the daily administration of 7.2 grams of Kyolic garlic powder for 6 months produced a modest reduction (of between 6.1 and 7%) in total cholesterol, compared with the placebo group. The more dangerous LDL cholesterol was reduced 4 to 4.6% in the Kyolic group. The heart-healthy benefits of garlic include protecting the endothelial lining of the arterial system against oxidative damage. A study published in Atherosclerosis (1999, 144:237-49) shows an actual reduction in buildup of fatty plaque in arteries in garlic-supplement users. Fatty plaque is comprised of many substances, including cholesterol. When plaque accumulates in the coronary arteries, the condition can lead to heart attack. In a study of 280 adults, German researchers reported that participants who took 900 mg of garlic powder a day had up to 18% less plaque in their arteries than those who took a placebo, or "dummy," powder. Male study participants who took a placebo had a 5.5% increase in plaque volume, while those who took the garlic powder experienced just a 1.1% increase in plaque buildup during the 4-year study period. By comparison, women who took the garlic showed a 4.6% decrease in plaque volume, while those who took the placebo powder had a 5.3% increase. Garlic may affect plaque buildup by reducing blood platelet stickiness (aggregation) and specifically preventing the oxidation of LDL cholesterol onto the lining of the arteries. Platelet aggregation helps plaque cling to the arteries. An April 1998 study reported on the effect of garlic on blood lipids, blood sugar fibrogen, and fibrinogenic activity of 30 patients who received 4 grams of garlic daily for 3 months. The patients were monitored at 1.5 and 3 months when it was determined that garlic had "significantly reduced total serum cholesterol and triglycerides, and significantly increased HDL cholesterol." With regard to fibrinogenic activity, it was determined that the garlic inhibited platelet aggregation (Prostagland. Leuk. Essent. Fatty Acids, April 1998, 58[4]:257-63). An earlier study in June 1994, the University of Massachusetts Medical School published a report that found that those U.S. adults who consumed one-half to one clove of garlic each day showed cholesterol levels that were reduced by 9% (JAMA, June 1, 1994, 271[21]:1660-61). A survey of 7 out of 8 studies on garlic showed that dosages of between 600 to 900 mg of garlic powder (Allium sativum L.) produced a 5 to 20% reduction in cholesterol and triglycerides. (Fortschr. Med. (Germany) 1990, 108[36]:49-54). Other studies have shown that much higher doses of garlic were required for cholesterol reduction. Human patients fed a daily dose of Kyolic ("Aged Garlic Extract") over a 10-month study showed that "adhesion to fibrinogen was reduced by 30%-compared to placebo . . . and that . . . the beneficial effect of garlic preparations on lipids and blood pressure extends also to platelet function" (Journal of Cardiovascular Pharmacology [United States], 1998, 31[6]:904-8). Note: Overall studies seem to indicate that dosages of garlic may be a factor in its efficacy. The suggested dose of high allicin garlic extract should be between 6000 mg and 8000 mg daily taken with meals. Since large amounts of garlic may cause stomach upset, we recommend that garlic be taken with the largest meal of the day. In summary, the mechanisms by which garlic have shown to protect against cardiovascular disease include the following: cholesterol reduction, preventing abnormal blood clot formation inside of blood vessels; protecting against LDL cholesterol oxidation; and protecting the endothelial lining of the arterial system against oxidation. A review of all the studies on garlic indicates that high doses are required for effective cholesterol reduction. If you were to use garlic alone to lower serum cholesterol, you should take 6000 to 8000 mg a day. When used in combination with other cholesterol-lowering nutrients, lower doses of garlic may be effective.