THE
STANDARD
(none)
Volume 1, No. 3
Managing Cholesterol: Naturally
Thomas G. Guilliams Ph.D.
To say that the concerns about cholesterol are rampant would be quite an
understatement. In fact, from much of the news and advertising, one would
think that cholesterol is a poison rather than the essential component that
it is. Yes, cholesterol is not only necessary for almost every cell in the
body, but our bodies produce (not ingest) most of the cholesterol we use.
Our main concern is with elevated blood (or serum) cholesterol and the
secondary conditions, such as lipid peroxidation and atherosclerosis, caused
by chronic increased levels of cholesterol in the blood. Since there are
thousands of articles and reviews on cholesterol, this article will only
briefly cover the metabolism and pharmaceutical management of cholesterol,
focussing primarily on the management of cholesterol using natural
ingredients.
Click on image
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Fig 1 "Leading causes of death in the United States for 1996
as reported by the Centers for Disease Control, modified by the adverse drug reaction (ADR)
statistics reported in JAMA, 1998; 279 (15): 1200-1205. COPD is
Chronic Obstructive Pulmonary Disease. Pneu/Flu is Pneumonia/Influenza."
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Cholesterol Overview: The Good, The Bad, and The Ugly
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We have all been guilty of reducing the whole of cholesterol metabolism down
into "good" (HDL) cholesterol and "bad" (LDL) cholesterol. While this is a
drastic over-simplification, it does help underscore that not all
cholesterol is hazardous to one's health.
Since cholesterol is not soluble in the blood, it must be carried to and
from the liver (the primary organ for synthesis and removal of the body's
cholesterol) via lipoprotein particles. The difference between lipoprotein
particles (LDL, IDL, VLDL, HDL etc) is not only their density, as the names
imply, but the composition of the proteins within the particle. Many of the
diseases associated with hypercholesterolemia are a result of genetic
mutations in these proteins or the cellular receptors that recognize these
proteins.
The cholesterol and fatty acid portion of LDL particles are susceptible
to oxidation, which can result in further free-radical damage to associated
vessel walls and increased adhesion leading to vessel damage, loss of
elasticity (arteriosclerosis) and build up of plaques along vessel walls
(atherosclerosis). This has placed increased serum cholesterol (and
especially LDL) as one of the leading causes of heart disease, itself the
leading cause of death in the Western world.
The relative danger of elevated total cholesterol (TC) should be assessed
with concurrent secondary risks such as smoking, obesity, family history,
homocysteine levels and others. According to the Adult Treatment Panel II of
the National Cholesterol Education Program (1), those with no heart disease
and relatively few secondary risks should be assessed as follows: TC <200
mg/dl are classified as desirable, TC from 200 to 239 mg/dl are classified
as border-line high, and those over 240 mg/dl are classified as high blood
cholesterol. As secondary risk factors are added, the relative risk of
cholesterol increases and should be treated more aggressively. HDL levels
below 35 mg/dl have also been associated with high risk of CHD.
According to a recent publication, the guidelines set forth for
cholesterol management by this panel are being neglected by a majority of
physicians caring for heart patients (2). While this was primarily a survey
of Midwestern States, it likely reflects the treatment throughout the rest
of the United States. In fact, unless patients ask specifically for
cholesterol screening, they are unlikely to be tested on a consistent basis,
even when they have previously been classified as having high cholesterol.
There are essentially 5 ways to reduce elevated serum cholesterol.
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Decrease the dietary intake of cholesterol, saturated fats, and trans
fatty acids: While increased levels of cholesterol in the diet have only a
small direct effect on total serum cholesterol levels, chronic ingestion of
cholesterol will decrease liver LDL receptors and keep serum levels high.
This will be discussed further in the "Diet" section of Natural Approaches.
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Increase bile production and secretion while providing a mechanism to
bind and remove bile: Probably one of the most under-utilized ways to
decrease serum cholesterol. Bile salts are synthesized primarily from
cholesterol, and when secreted from the liver to the gall bladder, bile
includes more cholesterol. Using choloretics to stimulate bile production
and secretion along with bile acid sequestering fibers is an extremely
helpful way to reduce serum cholesterol levels.
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Decrease the production of cholesterol: Although every cell in the body
can synthesize cholesterol, the cells in the liver provide most of the
cholesterol to the rest of the body. While feedback loops exist linking
cholesterol synthesis with LDL receptor function and overall fatty acid
metabolism, limiting precursors or reducing the amount (or activity) of
enzymes that produce cholesterol is an effective approach to reducing
cholesterol.
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Increase the liver's ability to bring in excess LDL particles from the
blood, while reducing it's ability to secrete LDL par-ticles into the blood
stream: This can be done by increasing the amount of LDL receptors on liver
cells, which decreases de novo synthesis in the liver and gives the
opportunity to remove the cholesterol via the bile or catabolic processes.
Various processes also regulate the amount of cholesterol (LDL particles)
secreted into the blood. These pathways can be modified to reduce the amount
of LDL particles secreted.
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Increase the cellular use and catabolism of cholesterol: This speaks for
itself. Through exercise and proper fatty acid metabolism, the body will
utilize its available cholesterol for cell membranes and steroid hormones.
Proper carbohydrate metabolism and blood sugar levels will keep fatty acid
metabolism (b-oxidation for energy) in balance and help keep cholesterol
levels down.
The best way to maintain healthy cholesterol levels or reduce already
elevated cholesterol levels is to use as many of the above mechanisms as
possible, simultan-eously. The potency of many pharmaceutical drugs makes
this difficult, if not dangerous. The natural approach, on the other hand,
would combine several ingredients, each having an independent mechanism for
reducing cholesterol levels at synergistic levels (sometimes sub-therapeutic
if considered alone). Let us compare these approaches.
Bile acid sequestrants:
Essentially this is a pharmaceutically synthesized fiber. Using a basic
anion exchange resin (cholestyramine), and artificial colors, sweeteners and
flavors; Bristol Laboratories produced Questran®. Cholestyramine adsorbs and
combines with bile, limiting its reabsorption via the enterohepatic
circulation. Side effects (constipation, gas, and intestinal pain) have lead
to very low compliance.
Nicotinic acid: The use of nicotinic acid (niacin) is considered one of the
first steps in the treatment of hypercholesterolemia. Usually 1-2 grams per
day are given to patients with low HDL, high LDL or high triglycerides.
Nicotinic acid reduces the amount of VLDL and LDL particle production and
excretion by the liver. Significant side effects (flushing,
gastro-intestinal, and liver toxicity) have kept this treatment from being
used in a large number of patients.
HMG-CoA reductase inhibitors (Statins): The most popular and well known of
these has been lovastatin (Mevacor®), and now Lipitor®. These drugs work by
inhibiting the enzyme 3-hydroxy-3-methylglutaryl-coenzyme A (HMG-CoA)
reductase, an enzyme that converts HMG-CoA to mevalonate (one of the rate
limiting steps in cholesterol synthesis). These should be avoided in
patients with liver conditions and has been shown to reduce levels of CoQ-10
(36), a necessary electron transport component of all tissues (especially
the heart). Long-term effect on steroid hormone synthesis is still being
researched.
Others: Other drugs exist, such as Clofibrate and Gemfibrozil, which are
used primarily for increased serum triglycerides although they have some
effects on both LDL and HDL levels. Some of these have quite serious side
effects and are being used only on difficult and high-risk patients.
In most cases, pharmaceutical drugs are unnecessary for the treatment of
hypercholesterolemia, (one obvious exception would be a patient with
homozygous familial hypercholesterolemia). The NCEP cholesterol
recommendation was to delay the use of pharmaceuticals in all patients with
high LDL and without other high CHD risk factors (1). The pharmaceutical
companies have another approach. Kohn and Roth say, "Many experts have
expressed concern that because of vigorous promotion by pharmaceutical
companies, these drugs are being urged on patients who might have benefited
from a less aggressive approach. Worse yet, there seems to be an increase in
noncardiac related deaths in patents who have been placed on lipid-lowering
drugs. Although the reason for this has not been discovered, it does suggest
that use of these drugs is not entirely innocuous and should not be
undertaken without adequate justification" (3). We could hardly agree more.
The use of dietary changes and proper use of natural ingredients can have a
dramatic effect on cholesterol levels as well as provide other effects that
benefit the patients overall health. The use of these ingredients will make
the need for pharmaceuticals unnecessary, except in rare, high-risk
patients.
While this topic has been covered over and over by
thousands of sources, it cannot be overemphasized. When a patient ingests
large quantities of fat, cholesterol and refined sugars; their cholesterol
levels will increase. Perhaps the greatest offender to cholesterol
management has come in like the Trojan Horse...trans fatty acids. Trans
fatty acids are formed by taking a "healthy" polyunsaturated oil (liquid)
and partially saturating it with hydrogen atoms (partially hydrogenated) to
make it more solid (margarine, vegetable shortening). This process forms
trans double bonds rather than the naturally occuring cis double bonds.
Heating polyunsaturated oils (as with most deep frying) will not only
produce trans fatty acids, but will produce oxidized oils. These unnatural
fats effect the entire metabolism of lipids by slowing down enzymatic
turnover rates and producing secondary metabolites that require further
conversion prior to their use or removal. The irony is that these products
have been considered healthier because they are cholesterol-free and made
from polyunsaturated oils.
We recommend using poly-unsaturated oils in their unheated, liquid form,
and using butter, coconut or palm kernel oil (we know this is against
current orthodoxy) in moderation when cooking with oils. These oils are
already saturated and will not be altered dramatically by heating and the
body should have ample enzymatic machinery to handle these fats in small
doses. Olive oil is a slight exception, as it is only singly unsaturated.
When using olive oil, add it with the food items (not to the hot pan alone)
and do not reuse oil for deep-frying.
The benefits of exercise are obvious. Not only will regular activity
increase carbohydrate and lipid metabolism, it will stimulate hormonal and
enzymatic activities which benefit fat metabolism. Since the work force is
moving increasingly away from strenuous labor and toward automated and
sedentary activities, exercise has become a recreational activity. [Our
nation's youth are now moving to sedentary recreation (Nintendo etc.) making
exercise labor once again.]
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Oxidized Cholesterol and Antioxidants
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When cholesterol loses electrons to
oxygen, it becomes oxidized and changes properties. This reaction can occur
as cholesterol-rich food is being processed or cooked, as well as in LDL
particles floating around in the blood. Researchers at the University of
California at San Francisco have now confirmed that oxidized cholesterol is
much more likely to form plaques on arterial wall (atherosclerosis) (4).
Oxidized cholesterol is not only more adhesive, but can cause further damage
to other lipid membranes by oxidative damage.
Significant ingestion of antioxidants is becoming more popular to combat
the damage induced by cholesterol in its oxidized form (5). One of the most
beneficial antioxidant in this regard is Vitamin E. The natural form of
vitamin E (d-a-tocopherol) is added directly to LDL particles by the body to
prevent and even reverse (reduce) the oxidized state of cholesterol. It is
best to use the natural form of Vitamin E, because while the artificial form
(dl-a-tocopherol) is a useful antioxidant in vitro, only approxamatly half
of this is added to membranes and LDL particles.
Other antioxidants have been shown to benefit oxidized cholesterol levels
directly or by "recharging" Vitamin E. One such antioxidant would be
a-Lipoic acid (formerly known as Thioctic acid). Having both fat-soluble and
water-soluble components, Lipoic Acid is able to bridge the recharging of
Vitamin E from Ascorbic Acid (a strictly water-soluble antioxidant). Other
excellent antioxidants include grape seed extracts, other flavonoid
components, selenium, glutathione, N-acetyl cysteine, natural b-carotene,
and zinc to name a few. We will have expanded coverage of antioxidants and
their use in subsequent newsletters.
One of the best ways to improve the body's use of fatty
acids is to give it fresh oils high in essential fatty acids. Fresh flax
seed, evening primrose, borage, black current seed and fish oils taken in
bulk or capsule form is an excellent way to increase the proper balance of
lipid metabolism and protect against the damage caused by oxidized
cholesterol and trans fatty acids. The oils should be as fresh as possible
and processed without chemicals or heat, as these polyunsaturated oils can
go rancid (oxidized) and possibly add to the problem.
While the use of niacin is considered to be an
excellent and conservative approach to cholesterol management, the side
effects have kept it from its frequent use. Inositol Hexaniacinate (IH) is
the only form of niacin not linked to significant side effects in clinical
trials. IH is a central inositol molecule with 6 niacin esters attached to
its six-membered ring. It is unknown why this form works just like niacin
(6), but without the side effects. Most of the research has used high doses
(up to 4 grams per day) of IH for the condition of intermittent claudication
(7,8). Most have found that 1000 to 1500 mg per day in divided doses is
quite adequate for lowering cholesterol, especially when added to other
cholesterol reducing natural ingredients.
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Choloretics and Natural Fibers
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One of the most underutilized natural
approaches to reducing cholesterol is the combined use of natural, bile
sequestering fibers such as psyllium or guar gum with potent natural
choloretics. There are many natural products that will stimulate bile
production and secretion like dandelion root, black radish root, beet leaf
tops, silymarin etc. One of the best and most consistent would be Globe
artichoke (Cynara scolymus L.) extract containing 1-2% cynarin. A daily dose
of 100-200 mg/day of a standardized artichoke extract will force the liver
to produce and dump bile into the gall bladder and then into the small
intestines. The liver will then take more cholesterol from the blood via its
LDL receptors and produce more bile. When this is combined with a
bile-sequestering fiber, the bile is unable to reabsorb and is removed with
the stool. This should be a natural part of any regimen dealing with liver
conditions, especially when fat or cholesterol is involved.
Much has been written about garlic's (Allium sativum L.) ability to
lower cholesterol, inhibit platelet aggregation and increase fibrinolysis
(18,19,20,21).
Garlic contains an odorless compound called alliin. When
crushed or chewed the alliin contacts an enzyme called allinase, which
converts alliin to allicin, the active and strong smelling component of
garlic. Allicin and ajoene seem to be able to interfere with the liver's
ability to synthesize cholesterol. Garlic helps prevent the oxidation of
cholesterol and even inhibits platelet aggregation. If your patients can
stand the smell, the best way to take garlic is fresh. Several cloves a day
ought to do it. Enteric coated tablets and capsules are available which
contain high amounts of alliin and allinase, which produces allicin once
ingested and mixed in the small intestines. 5-10 mg of allicin/day is
sufficient for most of the cardiovascular benefits derived from garlic.
Gugulipids come from the resin of the mukul myrrh tree
(Commiphora mukul). Used in India for centuries, gugulipids were researched
significantly since the 1960's for obesity and lipid disorders (23). The
active ingredients are the guggulsterones, which can be extracted with ethyl
acetate and standardized. Gugulipid has been shown to lower serum
cholesterol and triglycerides, lower LDL and raise HDL levels. It's primary
mode of action seems to be the ability to increase the number of hepatic LDL
receptors (22). It has also been implicated to increase bile secretion and
decrease cholesterol synthesis, possibly due to the increased LDL receptors
on liver cells. As a single ingredient, patients should try to get 50-75 mg
of guggulsterones per day in divided doses (24,29).
Much less (10-25 mg/day) can be used when added with synergistic ingredients for long-term
cholesterol management.
Tocotrienols are very closely related to Vitamine E
(tocopherols). Found abundantly in rice bran oil and palm oil, tocotrienols
may play a significant role in the natural approach to cholesterol
management. A significant body of research is available which shows direct
reduction of serum cholesterol
(25,26,27,28)
with the ingestion of
gamma-tocotrienols as well as closely related compounds. The mechanism is
thought to be a suppression of the enzyme HMG-CoA reductase, but rather than
inhibiting the enzyme (leading to build up of the enzyme as well as other
precursors), tocotrienols increase the breakdown of the enzyme. Available in
soft gel capsules, tocotrienols should be an adjunct therapy with capsule
and tablet form hypercholesterolemia products.
As a precursor to Coenzyme A, a necessary component of the
lipid catabolic process, pantethine would be a logical addition to lipid
lowering regimens. Interestingly, pantethine has been shown to lower
triglycerides and LDL while increasing HDL by a mechanism other than the
coenzyme A portion of the molecule (9). Pantethine is thought to inhibit
cholesterol synthesis (35) as well as accelerate fatty acid break down in
the mitochondria. When using pantethine as a single product, doses of 900 mg
are indicated. Sub-therapeutic doses can work synergistically with other
ingredients to reduce cholesterol and triglyceride levels.
As we mentioned previously, proper carbohydrate metabolism is tied
to lipid metabolism. Chromium has been used for a long time to increase
insulin's effect. Known as GTF (Glucose Tolerance Factor), a niacin
derivative of chromium has been used to help reduce serum glucose levels and
move the body into a state of lipid catabolism. This primarily helps reduce
triglycerides and to some extent cholesterol. Chromium supplementation has
been shown to increase HDL and decrease total cholesterol and triglycerides
(34,35). 100-200 mcg of chromium is
more than sufficient to improve glucose
tolerance and work synergistically with the other natural ingredients
mentioned.
Since heart disease is the number one cause of death in the western world,
and increased serum cholesterol one of the major risk factors, we cannot
overlook natural approaches to treating this condition. Decreasing dietary
intake of cholesterol, trans fatty acids and refined sugars is a foundation
for any natural approach. Using a wide variety of natural ingredients to
synergistically take advantage of their different cholesterol lowering
properties is the best natural approach to managing cholesterol. Since the
treatment will last for years, safety is a major concern. Using these
natural ingredients, in sub-therapeutic, but synergistic doses will ensure
good results, low side effects, and increased patient compliance. Becoming
familiar with these ingredients and how they work for different metabolic
types will make your approach to cholesterol management quit dynamic and
will soon become the standard.
- NCEP. Summary of the Second Report of the National Cholesterol Education
Program (NCEP) Expert Panel on Detection, Evaluation, and Treatment of High
Blood Cholesterol in Adults. JAMA. 1993; 269:3015-3023
[PubMed]
- McBride P. Et. al. Primary care practice adherence to National
Cholesterol Education Program guidelines for patients with coronary heart
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[PubMed]
- Cohn, R.M. and Roth, K.S. Biochemistry and Disease. 1996. Williams &
Wilkins Publishers, Baltimore pg 280.
- Staprans I. Et. al. Oxidized cholesterol in the diet accelerates the
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- Mosca L. Et. al. Antioxidant nutrient supplementation reduces the
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Cholesterol Overview 
Managing Cholesterol
The Natural Approach: