The cholesterol fighter's guide.

THE CHOLESTEROL FIGHTER'S GUIDE

What you need to know to keep cholesterol under control.

How can my cholesterol be 233? I don't eat that many eggs, and I've been walking regularly for the past two months!" Luann is a Barstow, California, homemaker and part-time real estate agent. She had just received the report on her cholesterol level at a public cholesterol screening held by Loma Linda University's School of Public Health. I was serving as the nutritional and lifestyle counselor at the screening, so she turned to me for answers. With a cholesterol level well above that recommended as desirable by the National Cholesterol Education Program (NCEP), she had reason to be concerned.

Luann is not unusual. Average blood cholesterol levels for adult American men and women are 211 and 215 milligrams of cholesterol per deciliter of blood (mg./dl.), respectively. This puts more than half of American adults in the borderline high or high blood cholesterol classifications shown here:

         National Cholesterol
         Education Program's

Total Cholesterol Classifications

Desirable:         less than 200 mg./dl.
Borderline High:         200-239 mg./dl.
High:               240 mg./dl. or more

Sizing up the risk factors.

The outlook for Luann was not as bleak as her cholesterol number initially indicated. Except for an apparently elevated cholesterol level, the only other coronary heart disease (CHD) risk factor she had was cigarette smoking. While she had cut down from two packs per day, she still was smoking. Her heart and lungs were suffering from the abuse, and she wanted desperately to quit. She found it encouraging to learn that most people who quit smoking will have made several attempts before they finally break free. Also, several good programs are available in her area if she needs extra help.

Another plus for Luann and millions like her is the power that diet and lifestyle have in controlling cholesterol levels. Dr. Kenneth Cooper, author of Aerobics and founder of the Cooper Clinic in Dallas, says people can expect cholesterol levels to fall an average of 50 mg./dl. through diet alone; much of the drop will occur in the first two or three months.

The lifestyle factor that has the greatest potential for lowering blood cholesterol is to eat less saturated fat. This is followed by the maintenance of a desirable body weight, eating foods high in water-soluble fiber, eating fewer cholesterol-rich foods, and exercising. Other factors that affect cholesterol levels include stress, heredity, and alcohol. (One should know also that there are at least two basic kinds of cholesterol--one is "good," and one is "bad.")

Getting to the fat of the matter.

Fats can be divided into three categories: polyunsaturated, monounsaturated, and saturated, referring to the amount of hydrogen in the fat molecules. Polyunsaturated fats are found mainly in liquid vegetable oils such as safflower, sunflower, corn, and soy, as well as in many nuts and seeds. Polyunsaturates lower LDL cholesterol, but not as much as saturated fats raise them--so a person can't undo the damage of a high saturated-fat diet by consuming more polyunsaturates. Diets rich in polyunsaturates tend to lower HDL-cholesterol slightly and may lower immunity, the body's ability to fight infection.

Rich sources of monounsaturated fats are olives, peanuts, and olive, peanut, and canola (rapeseed) oils. When substituted for saturated fats, monounsaturates lower LDL cholesterol without lowering HDL cholesterol, and it appears they do not lower immunity.

Saturated fats are generally solid at room temperature and are found in red meat, fish, poultry, dairy products, vegetable shortening (hydrogenated vegetable oil), and coconut, palm, and palm kernel oils. Of course, these are found as well in foods prepared with saturated fats, such as doughnuts, cookies, and cakes.

Fats yield a pleasant flavor and consistency to food, and some are necessary nutrients. Also, they are a plentiful source of food energy--and this is part of their problem. No matter what the source, they pack twice as many calories as carbohydrates or protein. America's love affair with fat is a major factor contributing to obesity.

Most Americans eat too much fat--about 37 percent of all our calories come from fat--and health experts recommend cutting back to about 25 to 30 percent. Cutting our saturated fat intake by about half is also advised, since saturates raise blood LDL cholesterol levels more than any other dietary factor.

Excess weight makes excess cholesterol.

Maintaining a desirable body weight is second in importance to eating less saturated fat. Being overweight adversely affects the heart in a number of ways. It tends to raise blood levels of LDL cholesterol and VLDL cholesterol (generally considered to be a mild indicator of heart disease risk). Overweight people are also inclined to suffer from high blood pressure and diabetes (both are CHD risk factors).

Losing excess weight can lower blood levels of LDLs and VLDLs and increase HDLs, especially when physical exercise is part of the weight management program. It's best to lose excess body weight gradually (about one or two pounds per week) by modestly restricting calories (particularly by eating less fat), exercising moderately every day (walking, swimming, cycling, gardening), and through social support and behavior modification.

And oat bran?

Dietary or soluble fiber found in oatmeal, oat bran, prunes, a number of beans, and some fruits and vegetables does lower blood cholesterol. Research by Dr. James W. Anderson of the University of Kentucky shows that eating foods rich in soluble fiber (oat bran, beans) often lowers blood cholesterol levels by 20 percent. Other studies indicate that by combining liberal quantities of soluble fiber with a low-fat, low-cholesterol diet, reductions as high as 30 percent can be achieved. You might want to discuss with your physician how certain bulk laxatives made from psyllium seed can be helpful in lowering blood cholesterol.

How soluble fiber helps lower blood cholesterol is not entirely clear. Most scientists believe the fiber disrupts the absorption of cholesterol and cholesterol-containing substances, such as bile from the intestine, and promotes their excretion.

Soluble fiber is not a panacea. It should be used as part of a low-fat diet, not in place of one. If you have a hard time finding oat bran, note that one cup of cooked oatmeal has about as much soluble fiber as two thirds of a cup of cooked oat bran. Remember also that in order to lower blood cholesterol effectively, good sources of soluble fiber should be eaten every day. Watch out! Some products advertised as good sources of oat or other soluble fiber also pack a fairly hefty dose of coconut oil or other saturated fat--so read the labels.

The scoop on cholesterol.

Eating less cholesterol is important for a heart-healthy lifestyle, but it's not as important as Luann thought. "Many people believe that controlling cholesterol simply means eating foods labeled `low-cholesterol' or `cholesterol-free,'" laments William P. Castelli, medical director of the Framingham Heart Study. Foods labeled "cholesterol-free" aren't necessarily good for your heart. They may be loaded with saturated fat, which in the end will elevate cholesterol levels more than by eating cholesterol itself. Be sure to read labels before you buy products.

Most shoppers presume that a brand of peanut butter or vegetable oil labeled "cholesterol-free" is healthier than another. Not only is the "cholesterol-free" label a meaningless nutritional claim (peanuts and vegetable oils do not contain cholesterol), it's an ambush for the unsuspecting consumer who is concerned about health. "Such advertising of food products muddies the cholesterol waters, often selling the image of good nutrition but not the fact," protests Jane Brody, personal health columnist for the New York Times.

The cholesterol in your bloodstream comes from two sources--what your body makes (every cell can make it, but most comes from the liver), and what your body absorbs from your diet (if you eat any). Dietary cholesterol raises blood levels of LDL cholesterol. There is also evidence suggesting that once absorbed into the bloodstream, dietary cholesterol promotes heart disease more than cholesterol produced by the body. This is a good reason why everyone, including people with low blood cholesterol, should avoid cholesterol-rich foods.

Cholesterol is found only in foods of animal origin, and cholesterol-rich foods tend to be high in saturated fat. High cholesterol foods include red meat, poultry, fish, cheese, whole milk, and especially organ meats and egg yolk (the protein-rich white of the egg has no cholesterol).

Don't be fooled by eggs labeled "low cholesterol." The determining factor is what they are compared to. Currently available food composition tables say an average large egg contains 274 mg. of cholesterol--but that value was determined years ago. Recent measurements of cholesterol in eggs, using an up-to-date technique, show that commercially available large eggs contain about 210 mg. of cholesterol.

The fitness connection.

Generally speaking, active people tend to have less premature heart disease than sedentary people. If a heart attack does strike, physically active people tend to recover more quickly. By helping to maintain desirable body weight, regular exercise promotes lower levels of triglycerides and LDL cholesterol. Another important benefit of exercise is higher levels of HDL cholesterol.

A 30- to 45-minute brisk walk (three to four miles per hour) each day can be enough to enhance heart health and improve cholesterol levels, says Dr. Kenneth Cooper. What is Dr. Cooper's advice for persons over age 40 who want to begin an exercise program? See your physician and get his or her go-ahead before exercising. If you are out of shape, don't overdo it at first. Begin slowly and gradually increase your activity each week until you reach a moderate and comfortable level. Walking is probably the best overall activity for most people.

Moving toward better heart health.

The first dietary step toward heart health is to eat less fat--especially saturated fat. Far easier than counting calories or grams of fat is identifying high-fat foods in your diet and replacing these with lower-fat alternatives. Table 1 lists a few examples of high-fat foods and lower-fat alternatives.

Three ounces of cooked lean ground beef, for example, contain about three times the fat of an equal portion of roasted chicken without the skin. Removing the skin from poultry does make a difference. Chicken without the skin has half the total fat of chicken with the skin. A person who wishes to reduce fat intake will choose the leanest cuts of meat and trim the fat before cooking. For the same reason, one should roast, bake, broil, or simmer meat, poultry, and fish.

White poultry meat is leaner than dark meat, and roasted turkey is even leaner than roasted chicken. Of all the meats, lean fish (flounder, sole, water-packed tuna) is the lowest in saturates and the highest in polyunsaturates. (The reduction of dietary fat is one of the reasons VIBRANT LIFE recommends a meatless diet.)

Switching from whole-fat to nonfat or low-fat dairy products can be an easy and painless way of reducing saturated fat intake. Take a look at Table 1. Notice the differences in fat and cholesterol between whole milk and nonfat milk and between ice cream and ice milk. Once you get used to nonfat milk, whole milk will taste like whipping cream.

Many people consider eating more healthfully like going to the dentist--they know it's a good idea, but just don't. "Most consumers equate healthful eating with a life of deprivation and self-denial," answers Jane Brody. "The good news is that it is possible to dramatically reduce your consumption of harmful fats and cholesterol and significantly reduce your blood cholesterol without undue sacrifices of eating pleasure."

Recipes can be modified any number of ways, making a dish that is more healthful and is still a delight to eat. Replace whole eggs with egg whites or egg substitutes. Substitute plain low-fat yogurt, blender-whipped low-fat cottage cheese, or buttermilk in recipes calling for sour cream or mayonnaise.

Bake your own goodies using healthful ingredients (such as oatmeal or oat bran, whole grains, and dried fruits and nuts in moderation) instead of buying doughnuts and pastries loaded with saturated fat, sugar, and cholesterol. Substitute fresh fruit or fruit salads for rich desserts. To make your own yummy "ice cream" at home, peel and freeze ripe bananas (or other fruits) until solid and then blend with nonfat milk or fruit juice--practically no fat or cholesterol!

When eating out, select restaurants that have salad and baked-potato bars, and avoid foods that are fried, smothered with cheese, or swimming in rich gravies or sauces. Don't be afraid to ask how dishes are prepared.

For meals with greater variety, more soluble fiber, and less cholesterol and saturated fat, try entrees made largely with legumes (beans) and whole grains. Dishes such as Cuban black beans and rice, chili with beans, tortillas, garbanzos, Oriental stir-fried vegetables with tofu, and lentil or split-pea soup can add an international flair to meals. Low in saturated fat and cholesterol-free, these can be delicious yet healthful alternatives to entrees made largely from meat, which are rich in cholesterol and saturated fat.

The lacto-ovovegetarian diet (no meat, but some eggs and dairy products) is long on nutrition and short on saturated fat and cholesterol. Usually composed of whole grains, pastas, beans and peas, vegetables, fruits, and moderate amounts of nuts, seeds, egg whites, and nonfat dairy products, it has definite health advantages. Seventh-day Adventist lacto-ovovegetarians living in California, for example, have less than half the heart disease death rate of other Californians. Adventist vegetarians who use no eggs or dairy products have an even lower heart disease death rate--it is less than one fourth that of other Californians.

Other factors affecting cholesterol levels.

Heredity can have a profound influence on cholesterol levels. Married couples who eat the same diet, for example, can sometimes have dramatically different cholesterol levels. The difference is the result of the wide individual variation in the way a person's cholesterol level responds to diet. This is primarily because of the unique biological makeup each person inherits from his or her parents.

For a few people (about 1 in 500), elevated cholesterol levels may be because of an inherited inability of the liver to remove LDL cholesterol from the blood. This may result in cholesterol levels of 300 to 500 mg./dl. and severe heart disease by one's mid-30s. An even rarer genetic defect of cholesterol metabolism can result in levels as high as 700 to 1,000 mg./dl.

Emotional stress of different types has been shown to raise cholesterol levels. Final examinations in school, job loss, surgery, and difficult childbirth have all been shown to increase cholesterol temporarily.

As most Americans age, their cholesterol levels usually rise. The reason is not entirely understood. Some researchers believe this is because of a gradual increase in body fat that most people experience as they age and become less active. As the percentage of body fat increases, the human machinery naturally produces more LDL cholesterol. This is another reason that keeping active and physically fit is important for all of us.

What about fish oils? There is some evidence that fish and fish oil supplements lower blood triglycerides, inhibit the tendency of the blood to clot, and may decrease blood pressure and increase levels of HDL cholesterol. However, there are adverse side effects as well, such as a potential for excessive bleeding, vitamin E deficiency, and possible vitamin A and D toxicity. "It is premature to recommend fish oil supplements to the general public. More definitive studies that prove their ability to prevent heart disease in humans are needed," advises Dr. Neil J. Stone of Chicago's Northwestern University Medical School.

Should alcohol be recommended for raising HDL cholesterol? Although moderate alcohol use (one to two drinks per day) has been shown to raise HDL cholesterol, it is not certain that the particular type of HDL involved is the kind that protects against heart disease. A number of factors raise HDL, including exercise, weight loss, insulin--even DDT. "Recommending alcohol to raise HDL violates one of our key rules as a therapy. Instead of improving other risk factors, it exacerbates them. It gives extra calories, so there's the problem with obesity; it raises blood pressure; and at higher quantities it increases the risk of stroke, liver disease, and accidents," Dr. Stone warns. "It is a very unwise therapy, in my view, especially when exercise is a far better way to raise HDL."

It takes time to develop new tastes, and it isn't always easy at first, but the experience can be "sweetened" with the knowledge that we're benefiting our loved ones and ourselves. When introduced slowly, gently, and reasonably, new ways will more likely lead to permanent change. "Chances are, you'll find out, as I have," says Jane Brody, "that as you gradually change your diet, your tastes will also change, and many of the no-no foods you now adore will lose their appeal." [Tabular Data 1 Omitted]

Robert Lee is a registered dietitian completing a doctorate in health science at Loma Linda University School of Public Health. He is also director of the school's community cholesterol screening program.