LOWERING CHOLESTEROL AND FAT LEVELS

DISCLAIMER: THIS PAGE CONTAINS A GENERAL EDUCATIONAL DISCUSSION ON THE ABOVE TOPIC. IT IS NOT HEALTH ADVICE AND SHOULD NOT BE CONSTRUED AS SUCH. YOU SHOULD NEVER RELY UPON THE INFORMATION GIVEN HERE. YOUR PARTICULAR CIRCUMSTANCES MAY WELL REQUIRE AN ENTIRELY DIFFERENT APPROACH. YOU SHOULD NOT MAKE ANY CHANGES IN YOUR MEDICATIONS, DIET, ACTIVITY, LIFESTYLE, ETC. WITHOUT FIRST CONSULTING A LICENSED PHYSICIAN IN YOUR AREA.

Whew! This is a really long and detailed page. So here's a quick summary. A healthy diet for the average person consists of fresh fruits and vegetables, nuts, soy (tofu), whole grain products (including brown rice, and whole grain cereals, breads and pastas), low fat dairy, egg whites, fish, and the white meat of chicken and turkey (without the skin). It minimizes fried foods, cake, cookies, chips, red meats, organ meats, white rice, pasta and bread made from refined grains (instead of whole grains), egg yolks, and dairy products that are not low fat.

Such a diet minimizes the intake of cholesterol, trans-fats, saturated fats and high glycemic index carbohydrates. It provides calories from mono- and poly-unsaturated fats, fish oils and low glcemic index carbohydrates. It also helps to suppress the appetite.

Controversies between the low-carb diets and low fat diets have not been resolved. The most important thing if one needs to lose weight is to limit the caloric intake - Eat Less! Where the calories come from is less important as long as the diet emphasizes the healthy fats and healthy carbs listed above.

It has been proven that high cholesterol and triglyceride levels are a significant contributor to heart disease. Lowering the cholesterol and triglyceride levels has been scientifically proven to prevent heart disease and prolong life. This has been proven for men and women, young and old. Even people with established heart disease can slow the progression of their disease and prolong their life by lowering their cholesterol and triglyceride levels.

The benefit of lowering the levels of cholesterol and fat is not something that takes a long time. Within six months of starting treatment for a high cholesterol level, the risk of heart disease is already reduced.

Lowering the serum cholesterol level achieves these benefits by slowing or preventing the growth of atherosclerotic plaques in the arteries. Some plaques may even get smaller with time. A lower cholesterol level also helps the arteries of the heart dilate during times of stress to provide additional blood flow to the heart muscle. Finally, many cholesterol lowering medications stabilize the atherosclerotic plaque so that it does not rupture-the process that is responsible for heart attacks.

CHOLESTEROL

As you would suspect, cholesterol in the food we eat contibutes to the high levels of cholesterol found in some people's blood. Equally important is the fact that the liver can actually create cholesterol. In many people, high cholesterol levels are due to an overproduction of cholesterol by the liver and not from eating too much cholesterol. The overproduction by the liver is usually on a genetic basis. Saturated fats and trans fats (see next section) in the diet also cause the liver to make more cholesterol.

You may have heard that our bodies contain a good cholesterol (known as HDL-cholesterol) which we want to keep as high as possible and a bad cholesterol (known as LDL-cholesterol) which we want to keep as low as possible. These terms refer to the different types of protein molecules the cholesterol gets attached to in our blood stream.

Cholesterol in food is not attached to any protein. All cholesterol in food should be considered bad cholesterol since it will become bad (LDL) cholesterol in our bodies.

The total cholesterol measured by blood tests is the total of the bad and good cholesterols. Since most of the cholesterol in our bodies is the bad (LDL) cholesterol, we like to see the total cholesterol as low as possible, generally less than 200. Blood tests can also measure the exact amount of the good and bad cholesterol which is a more accurate way to assess a person's risk of developing heart disease.

Cholesterol attached to the LDL protein is what damages our blood vessels and significantly contributes to heart disease. Naturally, we want to keep the LDL (bad) cholesterol as low as possible. This is done by minimizing our dietary intake of cholesterol as well as the dietary intake of saturated and trans fats which cause the liver to manufacture even more cholesterol. Often, medications are needed as well.

Changing the diet alone generally results in an average decrease of 6 to 11% in the LDL cholesterol although there is a lot of individual variability. Some people will have much greater responses to diet whereas others may have almost no change at all. Diets high in chlesterol lowering foods (soy, cereal fiber, nuts and plant sterols) may lower LDL cholesterol as much as 30%.

Very severe ultra low-fat diets such as the Ornish diet or other strict diets can result in a 40% lowering of the LDL-cholesterol. However, it is very difficult for most people to stick with those diets. Ultra low-fat diets also paradoxically cause the serum triglyceride (fat) level to rise.

Treatment of cholesterol is primarily guided by the level of the LDL cholesterol and less so by the level of triglycerides and HDL. The total cholesterol value and the ratio of total cholesterol to HDL cholesterol are rareley used by physicians in guiding treatment. Patients with known vascular disease and those at very high risk of having vascular disease (such as diabetics) are generally recomended to lower their LDL cholesterol to less than 100 and perhaps even lower than 70. More moderate risk people are advised to keep the LDL cholesterol under 130 while low risk people are preferred to keep the LDL level under 160.

The HDL protein takes cholesterol out of the lining of our blood vessels and protects against heart disease. So we like to keep the HDL (good) cholesterol as high as possible. This is accomplished by not smoking and by exercising. Weight loss in overweight people will also help raise the HDL level. Some cholesterol medicines also help raise the HDL cholesterol. Alcohol in moderation also raises the good cholesterol. Omega-3 fatty acids (fish oil) in place of other fats and low glycemic index carbohydrates will help raise the HDL cholesterol. Post-menopausal hormones (estrogen) raise the HDL cholesterol level too but despite this, they don't seem to protect against heart disease.

FAT

As stated above, cholesterol is not fat. However, it is important to discuss fat when talking about cholesterol because certain types of fat in the diet cause our bodies to make more cholesterol. Fat is also bad for the heart and blood vessels all by itself.

The serum triglyceride level is a measure of the circulating fat in the bloodstream. People with elevated triglyceride levels often have other risk factors for cardiovascular disease such as high blood pressure, diabetes, low HDL-cholesterol and being overweight. So, elevated triglyceride levels confer an increased risk of cardiovascular disease, as do high cholesterol levels..

There are four different types of fats in our diet: Saturated fats, monounsaturated fats, polyunsaturated fats and a fourth type which goes by several names including trans fats, hydrogenated fats and partially hydrogenated fats. All fats are equally fattening - containing nine calories per gram.

It is important to know about the different types of fats because two of them, the saturated fats and trans fats, cause the liver to make even more cholesterol. People eating diets high in saturated and trans fats have been shown to have an increased risk of developing and dying from cardiovascular disease. This is why we must carefully watch the amount of saturated and trans fat, as well as cholesterol, in the diet.

Saturated fat is primarily found in full fat dairy products, red meat and tropical oils such as palm and coconut oil.

Trans fats only occur rarely in nature (in meat from ruminant, cud chewing animals). Most of the trans fats in food are produced artificially by chemically treating (hydrogenating) naturally occuring unsaturated fats. Trans fats are used to convert oils to a solid or semisolid state such as in tub margarine or vegetable shortening. They are commonly found in baked foods, fried foods and snack foods.

The unsaturated fats (monounsaturated and polyunsaturated) in the diet don't raise the cholesterol level and actually have some health benefits but they are just as fattening and contribute to high serum triglyceride levels. Sources of these fats include fruits, vegetables, fish, vegetable oils and nuts. High carbohydrate diets also elevate the serum triglyceride level. As stated above, ultra low-fat diets paradoxically cause the serum triglyceride level to rise.

There is a debate over whether one of these unsaturated fats is better than the other.

There is a special type of beneficial polyunsaturated fat called omega-3 fatty acids. These are mostly found in fish oil but also in nuts, flaxseed, flaxseed oil, canola oil, and soybean oil. The best fish sources of omega-3 fatty acids are the fatty fish such as salmon, mackerel, herring, kipper, pilchard, sardine and trout.

The most important effect of omega-3 fatty acids in fish oil is to help stabilize the electrical conduction system of the heart. Clinical studies have shown that these fats do lower the risk dying from heart disease. Omega 3 fatty acid supplements (fish oil capsules) can be a consideration for people who don't like to eat fish.

Another benefit of fish oil is thinning of the blood. This effect also helps protect against heart disease but may increase bleeding risks. Fish oils also lower blood pressure slightly.

Unlike the other unsaturated fats, omega 3 fatty acids lower triglyercide levels. They have a minimal effect on LDL (bad) cholesterol. Unfortunately, they also lower the HDL (good) cholesterol and contain fat calories.

The nutrition labels on foods list the levels of cholesterol, total fat, saturated fat, monounsaturated fat and polyunsaturated fat. However, they don't yet list the amount of the trans fat. To see if a food product has trans fats, you must look in the ingredients section of the label for "hydrogenated" or "partially hydrogenated" fats, oils or vegetable shortening. As stated above, trans fats are generally found in margarine (especially stick margarine), vegetable shortening, baked foods, snack foods and fried foods. The government will require food manufacturers to list the trans fats along with the other three types of fats in 2006.

Elevated triglyceride levels are treated by weight loss, regular exercise, fish oil, smoking cessation and avoidance of alcohol. Total calories should be restricted. Fat intake does not have to be lowered below 25% to 30% of the total caloric intake. Excessive carbohydrate calories should be avoided. If these measures are ineffective, certain cholesterol lowering medications can also be used to lower the triglyceride level.

OFFICIAL RECOMMENDATIONS

The American Heart Association recommends that no more than 300 milligrams of cholesterol be consumed per day (that's about the amount in one egg yolk). They recommend that 25% to 35% of the calories eaten should come from fat. Higher fat intake increases the risk of heart disease. Fat intake less than 25% of the total calories probably doesn't have any further benefit and in fact, very low fat diets (such as 10% of total calories) may actually raise triglyceride (fat) levels and lower the level of good (HDL) cholesterol in the blood.

Saturated fat should account for less 7% of the total calories. Trans fat should be avoided as much as possible. Mononunsaturated and polyunsaturated fats should account for the remainder of fat calories.

Carbohydrates should account for at least 50% - 60% of the total caloric intake with the remainder coming from protein. Something called the glycemic index measures how much a given carbohydrate containing food raises the sugar level in the blood. Foods with a high glycemic index raise the blood sugar more than food with a low glycemic index. High glycemic index foods have been associated with lower HDL cholesterol levels, higher triglyeride levels and more heart disease.

The following three tables summarize the current American Heart Association Recommendations (reference: Lichtenstein A.,et al. Diet and Lifestyle Recommendations Revision 2006. A Scientific Statement From the American Heart Association Nutrition Committee. Circulation. 2006;114:82-96.)

TABLE 2. AHA 2006 Diet and Lifestyle Recommendations for Cardiovascular Disease Risk Reduction

� Balance calorie intake and physical activity to achieve or maintain a healthy body weight.

� Consume a diet rich in vegetables and fruits.

� Choose whole-grain, high-fiber foods.

� Consume fish, especially oily fish, at least twice a week.

� Limit your intake of saturated fat to <7% of energy, trans fat to <1% of energy, and cholesterol to <300 mg per day by

� choosing lean meats and vegetable alternatives;

� selecting fat-free (skim), 1%-fat, and low-fat dairy products; and

� minimizing intake of partially hydrogenated fats.

� Minimize your intake of beverages and foods with added sugars.

� Choose and prepare foods with little or no salt.

� If you consume alcohol, do so in moderation.

� When you eat food that is prepared outside of the home, follow the AHA Diet and Lifestyle Recommendations.

TABLE 3. Practical Tips to Implement AHA 2006 Diet and Lifestyle Recommendations

Lifestyle

� Know your caloric needs to achieve and maintain a healthy weight.

� Know the calorie content of the foods and beverages you consume.

� Track your weight, physical activity, and calorie intake.

� Prepare and eat smaller portions.

� Track and, when possible, decrease screen time (eg, watching television, surfing the Web, playing computer games).

� Incorporate physical movement into habitual activities.

� Do not smoke or use tobacco products.

� If you consume alcohol, do so in moderation (equivalent of no more than 1 drink in women or 2 drinks in men per day).

Food choices and preparation

� Use the nutrition facts panel and ingredients list when choosing foods to buy.

� Eat fresh, frozen, and canned vegetables and fruits without high-calorie sauces and added salt and sugars.

� Replace high-calorie foods with fruits and vegetables.

� Increase fiber intake by eating beans (legumes), whole-grain products, fruits, and vegetables.

� Use liquid vegetable oils in place of solid fats.

� Limit beverages and foods high in added sugars. Common forms of added sugars are sucrose, glucose, fructose, maltose, dextrose, corn syrups, concentrated fruit juice, and honey.

� Choose foods made with whole grains. Common forms of whole grains are whole wheat, oats/oatmeal, rye, barley, corn, popcorn, brown rice, wild rice, buckwheat, triticale, bulgur (cracked wheat), millet, quinoa, and sorghum.

� Cut back on pastries and high-calorie bakery products (eg, muffins, doughnuts).

� Select milk and dairy products that are either fat free or low fat.

� Reduce salt intake by

�comparing the sodium content of similar products (eg, different brands of tomato sauce) and choosing products with less salt;

�choosing versions of processed foods, including cereals and baked goods, that are reduced in salt; and

�limiting condiments (eg, soy sauce, ketchup).

� Use lean cuts of meat and remove skin from poultry before eating.

� Limit processed meats that are high in saturated fat and sodium.

� Grill, bake, or broil fish, meat, and poultry.

� Incorporate vegetable-based meat substitutes into favorite recipes.

� Encourage the consumption of whole vegetables and fruits in place of juices.

TABLE 4. Two Examples of Daily Dietary Patterns That Are Consistent With AHA-Recommended Dietary Goals at 2000 Calories

Eating Pattern	DASH^*	TLC	Serving Sizes
Grains	6 to 8 servings per day	7 servings per day	1 slice bread; 1 oz dry cereal^�; cup cooked rice, pasta, or cereal
Vegetables	4 to 5 servings per day	5 servings per day	1 cup raw leafy vegetable, cup cut-up raw or cooked vegetable, cup vegetable juice
Fruits	4 to 5 servings per day	4 servings per day	1 medium fruit; cup dried fruit; cup fresh, frozen, or canned fruit; cup fruit juice
Fat-free or low-fat milk and milk products	2 to 3 servings per day	2 to 3 servings per day	1 cup milk, 1 cup yogurt, 1 oz cheese
Lean^\|\| meats, poultry, and fish	<6 oz per day	5 oz per day
Nuts, seeds, and legumes	4 to 5 servings per week	Counted in vegetable servings.	cup (1 oz), 2 Tbsp peanut butter, 2 Tbsp or oz seeds, cup dry beans or peas
Fats and oils	2 to 3 servings^# per day	Amount depends on daily calorie level	1 tsp soft margarine, 1 Tbsp mayonnaise, 2 Tbsp salad dressing, 1 tsp vegetable oil
Sweets and added sugars	5 or fewer servings per week	No recommendation	1 Tbsp sugar, 1 Tbsp jelly or jam, cup sorbet and ices, 1 cup lemonade

*Dietary Approaches to Stop Hypertension. For more information, please visit http://www.nhlbi.nih.gov/health/public/heart/hbp/dash.
Therapeutic Lifestyle Changes. For more information, please visit http://www.nhlbi.nih.gov/cgi-bin/chd/step2intro.cgi. TLC includes 2 therapeutic diet options: Plant stanol/sterol (add 2 g per day) and soluble fiber (add 5 to 10 g per day).
Whole-grain foods are recommended for most grain servings to meet fiber recommendations.
This number can be less or more depending on other food choices to meet 2000 calories.
�Equals to 1 cups, depending on cereal type. Check the product�s Nutrition Facts Label.
\|\|Lean cuts include sirloin tip, round steak, and rump roast; extra lean hamburger; and cold cuts made with lean meat or soy protein. Lean cuts of pork are center-cut ham, loin chops, and pork tenderloin.
#Fat content changes serving counts for fats and oils: For example, 1 Tbsp of regular salad dressing equals 1 serving; 1 Tbsp of low-fat dressing equals serving; 1 Tbsp of fat-free dressing equals 0 servings.

The Mediterranean diet refers to the typical diet of Mediterranean people such as those living in the southern European countries. These people have a low incidence of heart disease.

The Mediterranean diet was studied in heart attack survivors. Compared to a typical American diet, the Mediterranean diet led to a 50% to 70% lower risk of recurrent heart disease. This diet is consistent with the American Heart Association recommendations above as well as the specific dietary tips in the next section of this page.

The Mediterranean diet emphasizes monounsaturated fats, fruits, vegetables, grains such as bread and cereal, potatoes, beans, nuts, seeds and fish. Eggs and red meat are avoided. Poultry is consumed in low to moderate amounts. Olive oil and canola oil are the preferentially used oils. Instead of butter, margarine with low saturated fat but containing extra fats known as linoleic and alpha-linolenic acids is used. Wine is allowed with meals in moderation. Here is a Mediterranean diet food pyramid (from Frank Hu, New England Journal of Medicine 348:2595; June 26, 2003):

PRACTICAL TIPS-WHAT TO EAT AND HOW TO COOK

How does one accomplish these goals? The answer is not simply to eliminate foods that you enjoy but rather, to substitute equally enjoyable, healthy alternatives as much as possible.

There is no cholesterol in fruit or vegetables. The main dietary sources of cholesterol and saturated fat include red meats, organ meats, and dairy products. The skin of chicken and turkey also has a lot. Dark meat has more than white meat. The tropical oils, coconut and palm, are very high in saturated fat. Hydrogenated fats are found in margarine (especially stick margarine), vegetable shortening, baked foods, fried foods and snack foods.

When a person eats meat it should be mostly fish and white meat chicken or turkey (without the skin). People who eat fish once or twice weekly definitely have less heart disease than those who don't. Don't obsess too much about which fishes are lowest in fat or cholesterol. That will just make it even more difficult to stick with and enjoy the diet. Any diet high in fish is associated with a decreased risk of heart disease. Shellfish has some cholesterol but is low in fat and is okay to eat. Shrimp has the highest cholesterol content of all the shellfish.

If red meat is eaten, it should be a lean cut. Examples include flank steak, sirloin tip, round steak, rump roast, veal chops, small loin lamb chops and lean ham. Processed meats such as bologna, bacon and frankfurters are very high in fat but low fat varieties are now becoming available. Organ meats such as liver and sweetbreads are high in cholesterol and should be eaten only rarely.

If dairy products are consumed, they should be the 1% low-fat or no fat variety. The cholesterol in eggs is all in the yolk. Eating egg whites is a good source of dietary protein. If you like the yellow color, cholesterol-free egg substitutes are available in the supermarket. A recent study showed that consumption of one egg a day does not contribute significantly to the development of heart disease. This may be due to antioxidant vitamins and unsaturated (rather than saturated) fats in eggs that counterbalance the deleterious effect of the cholesterol.

Try to use liquid margarine such as margarine made from rapeseed oil, soybean oil or olive oil in place of butter. Substitute 1% or no fat milk for regular milk. Ditto for yogurt. Sherbet or low fat yogurt is preferable to ice cream. Low fat cheeses can be identified as those containing less than 5 grams of fat per ounce. There are low fat varieties of cottage, American, Swiss, cheddar and Monterey cheeses. Ricotta, part-skim milk mozzarella and Jarlsburgh are other examples of low fat cheeses.

Margarine has less saturated fat than butter but may contain more hydrogenated (trans) fat. Stick margerine has very high amounts of hydrogenated fats and may be actually worse for the cholesterol level than butter. The softer margarines that come in a tub or liquid form are better for the cholesterol level because they are lower in hydrogenated fat and saturated fat than stick margarine and butter. The best bet is to look for margarine made with unsaturated liquid vegetable oil. Soybean or olive oil are also safe substitutes.

Now there are available margarines and salad dressings that contain naturally occuring chemicals derived from plants called "sterols" and "stanols." These substances block the absorption of cholesterol by the intestines. The use of sterol-enriched products (such as Benecol, Smart Balance Omega Plus and Take Control margarines, Lifetime Low Fat cheese, Minute Maid Heart Wise Orange Juice, Nature Valley Healthy Heart Chewy Granola Bars, Rice Dream Heartwise Rice Drink, Yoplait Healthy Heart Yogurt, CocoaVia chocolates) may lower the level of bad cholesterol in the body by 10% to 15%.

When cooking with oil, palm, cottonseed and coconut oils should be avoided in favor of olive, corn, canola (rapeseed), sunflower and safflower oils. Avoid fried foods in restaurants unless you know what kind of oil they were cooked in.

Avoid commercially prepared and processed foods such as cakes, cookies, crackers and other snack foods made from saturated or hydrogenated fats. Chocolate, nuts and avocados are also high in fat (however, the fat in nuts and avcados is unsaturated fat). If you are not sure, read the nutrition label and ingredients.

Dietary fiber helps lower cholesterol. Fiber is found in whole grains such as oat, whole grain breads and cereal; legumes such as beans, peas, and lentils; citrus fruits and psyllium containing cereals and laxatives.

In general, it is prudent to eat a diet high in fruits and vegetables. Two to four servings per day of fresh, frozen, canned or dried fruit and three to five servings per day of fresh, frozen or canned vegetables (without added fat, salt or sauce) will suffice. These types of diets are definitely associated with lower cholesterol levels and a reduced incidence of heart disease. In addition to containing fiber, they also contain antioxidant substances including polyphenols and vitamins A,C, and E (see Antioxidants and the Heart).

Fruits and vegetable also contain phytoestrogens (isoflavones) which lower cholesterol and act as antioxidants. Phytoestrogens are naturally occuring estrogens found in plants. They include isoflavones such as genistein, glycetein and daidzein. These are found in soy products such as soybeans, tofu and miso soup. They are also found in tea, cereals, legumes, onions and broccoli and fruits such as apples, cranberries, and strawberries. Isoflavones also have a mild blood thinning effect in addition to their antioxidant activity and their ability to lower cholesterol and triglyceride levels.

Fruits and vegetables also contain sterols (sitosterol) and stanols (sitostanol) which block the absorption of dietary cholesterol from the intestine to help lower the cholesterol level.

Plant sulfur compounds are found in garlic, leeks and onions and may be responsible for the cholesterol lowering effect reported in some studies by garlic. The active component of garlic is allicin. Do note however that large doses of garlic can have serious side effects, including anemia and allergic reactions. The most recent studies published on garlic actually found that it had only a minimal effect, if any, on serum cholesterol levels.

Replacing animal sources of protein with vegetable sources helps avoid the cholesterol inherent in most meat products. Various combinations of vegetables, legumes (peas, beans and lentils), fruits, nuts (walnuts, almonds, pecans), seeds (sesame and sunflower) and grains (oat, rice, corn, wheat, barley, rye) represent as good a source of protein as red meat.

Note that nuts are high in fat and therefore are fattening but it is mostly unsaturated fat. Nuts help lower the amount of bad LDL cholesterol and raise the amount of good HDL cholesterol. Nuts also contain omega-3 fatty acids, the good type of fat found in fish.

Soy protein may lower the bad cholesterol level slightly. Soy also contains antioxidant flavenoids (isoflavones) as well as other substances that do things beyond just improving the cholesterol levels to help prevent heart disease. Tofu is processed soy and contains lesser amounts of these substances.

Poultry and fish also supply protein and are lower in fat and cholesterol than red meat.

Beware: even vegetables can be unhealthy if fried in an oil high in saturated fat or dipped in a high fat spread.

Vegetarians should note that their diet contains no vitamin B12 and they should discuss taking supplemental B12 with their physician.

Complex carbohydrates (starch) have traditionally been considered preferable to simple carbohydrates (sugar). However, judging the effect of carbohydrates on cholesterol levels may have to take into account the glycemic index rather than simply considering whether the carbohydrates are simple versus complex.

Remember that all carbohydrates have calories and if you ingest more calories than you burn off, you will gain weight and the triglyceride (fat) levels in the blood will increase.

Whole grain breads and cereals, legumes such as peas and beans, as well as fruits and vegetables are healthy carbohydrate sources and they decrease cardiovascular risk.

Refined grain products such as white bread and white rice are derived from whole grain products. They are stripped of their vitamins, minerals, fiber and other plant nutrients and have a higher glycemic index. Pasta and potatoes also have a higher glycemic index than whole grain foods.

One scientific study compared a low fat diet (18% of calories from fat) with no restrictions on the types of carbohydrates eaten to a diet with 30% fat but restricting carbohydrates to those with a low glycemic load. Several interesting discoveries were made. People eating the low fat diet demonstarted a slowing of their metabolism. This is a common problem with many diets. It impedes the ability to continue to lose weight. Remarkably, this slowing of the metabolism was not seen in people eating the low glycemic load diet. People in the low glycemic load group reported less hunger too. The low glycemic index diet also led to less insulin resistance (which should help ameliorate or prevent diabetes), lower triglyceride levels, lower blood pressure and lower levels of inflammatory proteins in the bloodstream. However there was no significant difference in weight loss or total body fat between the two groups.

Other studies of various diets including very low carbohydrate diets (Atkins), ultra-low fat diets (Ornish) and moderate diets (Weight Watchers), amongst others have shown that the amount of weight lost depends on how compliant a person is with a diet. The actual diet chosen does not seem to matter (low carbohydrate diets tend to cause more rapid weight loss early on but the long term weight loss ends up being the same regardless of which diets is followed). The ability to stick with a diet is poor for all types studied.

Low fat diets reduce the bad, LDL, cholesterol while low cabohydrate diets have no effect on the LDL levels. However, low carbohydrate diets raise the good HDL cholesteol and lower triglycerides and improve control of the blood glucose (sugar) level whereas as low fat diets actually lower the HDL level and raise the triglyceride level.

Healthy snacks include air-popped popcorn, graham crackers, melba toast, rye crisps, soda crackers, fat free pretzels and crackers, bread sticks, English muffins, cereals as well as fruits and vegetables. Low-fat cookies include animal crackers, ginger snaps and molasses cookies.

Healthy desserts include fruit, ices, sherbet, angel food cake, jello, low fat yogurt and low fat ice milk.

Watch out for high fat and cholesterol gravy, sauces, salad dressings, spreads and toppings that can undo all the good of an otherwise healthy meal.

Be extra careful when eating in a restaurant or eating a hurried meal. These are the situations where we tend to fall off the wagon.

Low fat methods of food preparation include baking, broiling, stir frying, microwaving, steaming, grilling, poaching and roasting. Breading and frying should be avoided. When frying is done, it should be done with minimal amounts of the cooking oils listed above or in a nonstick pan. When roasting, first trim the fat and then place the meat on a rack so the fat can drip away. Soups and stews should be chilled for a few hours so that the congealed fat on top can be removed.

Substitute low fat and cholesterol ingredients for high fat and cholesterol ingredients. Use egg whites or substitutes instead of whole eggs. Use margarine or oil fortified with crackers instead of butter or hard shortening. Substitute cocoa for baking chocolate.

Tofu (soy) can take the place of eggs or dairy products in many recipes. Soy flour and isolated soy protein can be added to baked foods to improve their nutritional quality without affecting their taste. Texturized vegetable protein made from soy can be used as a meat extender or replacement.

Alcohol in moderation seems to prevent heart disease. This may be due to the fact that it raises the level of good cholesterol in our blood and has antioxidant and blood thinning effects. Substances in grapes and red wine called phytoestrogens (isoflavones) such as resveratrol are probably responsible for these effects. Polyphenols are also an antioxidant substance found in red wine

Coffee may raise cholesterol levels, particularly if the coffee is boiled directly in the water. Filtered coffee may have less of an effect on cholesterol. Coffee from Arabica beans will have less of an effect on cholesterol than coffee from Robusta beans. It is probably not the caffeine but other substances in the coffee that cause it to raise cholesterol levels.

The goal of dietary modification is not to eliminate favorite foods but to replace them with satisfying alternatives. It is recognized that no one will stick with a diet they don't enjoy. Meeting with a dietician can be very helpful in planning an enjoyable and healthy diet and well worth the small, nominal charge. It is also important to note that no food is totally given up forever. A high cholesterol meal, once in a great while, such as on a special occasion will do no harm. Moderation and common sense are all that are required.

OTHER DIETARY RESOURCES

The International Task Force for Prevention of Coronay Heart Disease has a comprehensive table of dietary recommendations that is quite helpful.

The American Heart Association has a number of cookbooks for enjoyable, healthy food and a helpful page on Diet and Nutrition.

Also recommended is The Stanford University Healthy Heart Cookbook and Life Plan by Helen Cassidy Page, John Speer Schroeder, M.D., and Tara Coghlin Dickson, M.S., R.D. published by Chronicle Books, San Francisco, CA, 1996.

Another excellent book is Good Fat, Bad Fat by Glen Griffin, M.D. and William Castelli, M.D. published by Fisher Books, Yucson, AZ, 1997

Other helpful websites:

The Food and Nutrition Center from the Mayo Clinic

The Nutrition Page and the Heart Diseases Prevention Page from the National Institutes of Health..

There are other dietary web sites on our Recomended Links page.

SPIN (Special Program in Nutrition) developed by Ann H. Snyder, R.D., Lucy B. Adams, M.S. and Thomas P. Bersot, M.D., PhD. of the Gladstone Institute of Cardiovascular Disease is a curriculum for a heart healthy diet designed to be taught to third and fourth graders as well as their parents. It served as a source for some information on this web page. Their web page gives instructions on how you can obtain their excellent cookbook and curriculum.

The definitive book on the nutritional values of almost any food you can think of is Bowes & Church's Food Values of Portions Commonly Used, 17th edition by Jean A.T. Pennington Ph.D., R.D. published by Lippincott Williams & Wilkins Publishers, Philadelphia 1997.

CHOLESTEROL LOWERING MEDICATIONS

As we stated above, in many people a high level of bad (LDL) cholesterol is on a genetic basis. Their bodies simply produce too much cholesterol, even if they eat a perfect diet. In these people, cholesterol lowering medications should be considered. There is no convincing evidence that cholesterol lowering medications cause cancer or death from reasons other than heart disease. Cancer causes the low cholesterol level, not vice versa.

The choice of cholesterol lowering medication must be made by a licensed physician. Niacin is a very effective cholesterol lowering medication that is available over the counter but (like all other medicines), it can have significant and serious side effects. It should only be used under a physician's supervision. There are now many well tolerated and safe medications to lower cholesterol levels that your physician can prescribe if needed.

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LOWERING CHOLESTEROL AND FAT LEVELS

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