Dietary changes that may be helpful
Eating animal foods containing saturated
fat is linked to high cholesterol levels1 and heart disease.2 Significant amounts of
animal-based saturated fat are found in beef,
pork, veal,
poultry (particularly in poultry skins and dark meat), cheese,
butter, ice cream, and all other forms of
dairy products not labeled “fat
free.” Avoiding consumption of these foods reduces cholesterol and has been reported to
reverse even existing heart disease.3
Unlike other dairy foods, skimmed milk,
nonfat yogurt, and nonfat cheese are essentially fat-free. Dairy products
labeled “low fat” are not particularly low in fat. A full 25% of calories in 2% milk come from fat.
(The “2%” refers to the fraction of volume filled by fat, not the more important
percentage of calories coming from fat.)
In addition to large amounts of saturated fat from animal-based foods, Americans eat small
amounts of saturated fat from coconut and palm oils. Palm oil has been reported to elevate
cholesterol.4 5 Research regarding coconut oil is mixed, with some trials finding no link
to heart disease,6 while other
research reports that coconut oil elevates cholesterol levels.7 8
Despite the links between saturated fat intake and serum cholesterol levels, not every
person responds to appropriate dietary changes with a drop in cholesterol. A subgroup of
people with elevated cholesterol who have what researchers call “large LDL
particles” has been reported to have no response even to dramatic reductions in dietary
fat.9 (LDL is the “bad” cholesterol most associated with an increased
risk of heart disease.) This phenomenon is not understood. People who significantly reduce
intake of animal fats for several months but do not see significant a reduction in cholesterol
levels should discuss other approaches to lowering cholesterol with a doctor.
Yogurt, acidophilus milk, and kefir are fermented milk products that have been
reported to lower cholesterol in most,10 11 12 13
14 15 16 but not all, double-blind and other controlled
research.17 18 19 Until more is known, it makes sense for
people with elevated cholesterol who consume these foods, to select nonfat varieties.
Eating fish has been reported to increase
HDL cholesterol20 and is linked to a reduced risk of heart disease in
most,21 but not all, studies.22 Fish contains very little saturated fat, and fish oil contains EPA and DHA, omega-3 fatty acids that appear to protect
against heart disease.23
Vegetarians have lower
cholesterol24 and less heart disease25 than meat eaters, in part because
they avoid animal fat. Vegans (people who eat no meat, dairy, or eggs) have the lowest cholesterol levels,26
and switching from a standard diet to a vegan diet, along with other lifestyle changes, has
been reported to reverse heart disease in controlled research.27 28
Dietary cholesterol
Most dietary cholesterol comes from egg yolks. Eating eggs has increased serum cholesterol in
most studies.29 However, eating eggs does not increase serum cholesterol as much as
eating foods high in saturated fat, and eating eggs may not increase serum cholesterol at all
if the overall diet is low in fat.30
Egg consumption does not appear to be totally safe, however, even for people consuming a low-fat diet. When cholesterol from eggs is
cooked or exposed to air, it oxidizes. Oxidized cholesterol is linked to increased risk of heart disease.31 Eating eggs also
makes LDL cholesterol more susceptible to damage, a change linked to heart
disease.32
Whether or not egg eaters are more likely to die from heart disease is a matter of
controversy. In one preliminary study, egg eaters had a higher death rate from heart disease,
even when serum cholesterol levels were not elevated.33 However, another
preliminary study found no evidence of an overall significant association between egg
consumption, and risk of heart disease or
stroke, except in people with
diabetes.34 Until more is known, limiting egg consumption may be a good idea,
particularly for people with existing heart disease or diabetes.
While coconut oil is high in saturated fat, some evidence suggests it does not cause
unhealthy changes in blood cholesterol levels compared with other saturated fats. In a
controlled study of people with high cholesterol, coconut oil resulted in higher total and LDL
cholesterol levels compared with safflower oil (a
polyunsaturated oil), but lower levels compared with butter, while HDL levels were similar
for all three diets.35 Another controlled study compared coconut oil with canola
oil,36 and found that coconut oil raised total and LDL cholesterol in people with
high cholesterol who were not taking cholesterol-lowering drugs, but did not affect these
levels in people who were taking these drugs. HDL levels were not reported in this study.
Fiber
Soluble fiber from beans,37 oats,38 psyllium seed,39 glucomannan, and fruit pectin40 has lowered cholesterol
levels in most trials.41 42 Doctors often recommend that people with
elevated cholesterol eat more of these high-soluble fiber foods. However, even grain fiber (which contains insoluble fiber
and does not lower cholesterol) has been linked to protection against heart disease, though
the reason for the protection remains unclear.43 It makes sense for people wishing
to lower their cholesterol levels and reduce the risk of heart disease to consume more fiber
of all types. Some trials have used 20 grams of additional fiber per day for several months to
successfully lower cholesterol.44 Psyllium has also been found to enhance the
effect of the cholesterol-lowering drug
simvastatin.45
Oat bran is rich in a soluble fiber called
beta-glucan. In 1997, the U.S. Food and Drug Administration passed a unique ruling that
allowed oat bran to be registered as the first cholesterol-reducing food at an amount
providing 3 grams of beta-glucan per day, although some evidence suggests this level may not
be high enough to make a significant difference.46 Several double-blind and other
controlled trials have shown that oat bran47 48 49 and oat
milk50 supplementation may significantly lower cholesterol levels in people with
elevated cholesterol, but only weakly lowers them in people with healthy cholesterol
levels.51
Flaxseed, another good source of soluble
fiber, has been reported to lower total and LDL cholesterol in preliminary
studies.52 53 A double-blind trial found that while both flaxseed and sunflower seed lowered total cholesterol, only
flaxseed significantly lowered LDL.54 Amounts of flaxseed used in these trials
typically range from 30–50 grams per day. A controlled trial found that partially
defatted flaxseed, containing 20 grams of fiber per day, significantly lowered LDL
cholesterol, suggesting that at least one of the cholesterol-lowering components in flaxseed
is likely to be the fiber in this product, as opposed to the oil removed from it.55 Controlled trials of
flaxseed oil alone have shown inconsistent
effects on blood cholesterol.56 57 58
Alpha-linolenic acid
Doctors and researchers are interested in alpha-linolenic acid (ALA)—the special omega-3
fatty acid found in large amounts in flaxseeds and flaxseed oil. ALA is a precursor to EPA, a
fatty acid from fish oil that is believed to
protect against heart disease. To a limited extent, ALA converts to EPA within the
body.59 However, unlike EPA, ALA does not lower triglyceride levels (a risk factor for heart
disease).60 Preliminary research on the effects of ALA from flaxseed has produced
conflicting results.
In 1994, researchers conducted a study in people with a history of heart disease, using
what they called the “Mediterranean” diet.61 The diet was significantly
different from what people from Mediterranean countries actually eat, in that it contained
little olive oil. Instead, the diet included a
special margarine high in ALA. Those people assigned to the “Mediterranean” diet
had a remarkable 70% reduced risk of dying from heart disease compared with the control group
during the first 27 months. Similar results were also confirmed after almost four
years.62 Although cholesterol levels fell only modestly in the
“Mediterranean” diet group, the positive results suggest that people with elevated
cholesterol attempting to reduce the risk of heart disease should consider such a diet. The
diet was high in beans and peas, fish, fruit,
vegetables, bread, and cereals; and low in meat,
dairy fat, and eggs. Although the authors
believe that the high ALA content of the diet was partially responsible for the surprising
outcome, other aspects of the diet may have been partly or even totally responsible for
decreased death rates. Therefore, the success of the “Mediterranean” diet does not
prove that ALA protects against heart disease.63
Soy
Tofu, tempeh,
miso, and some protein powders in health food stores, are derived from soybeans. In 1995, an analysis of many trials proved
that soy reduces both total and LDL cholesterol.64 Since then, other double-blind
and other controlled trials have confirmed these findings.65 66
67 68 Trials showing statistically significant reductions in cholesterol have
generally used more than 30 grams per day of soy protein. However, if soy replaces animal
protein in the diet, as little as 20 grams per day has been shown to significantly reduce both
total and LDL cholesterol.69 Isoflavones found in soy beans appear to be key
cholesterol-lowering ingredients of the bean,70 71 but animal research
suggests other components of soy are also important.72 73
Sugar
Eating sugar has been reported to reduce protective HDL cholesterol74 and increases
other risk factors linked to heart disease.75 However, higher sugar intake has been
associated with only slightly higher risks of heart disease in most reports.76
Although the exact relationship between sugar and heart disease remains somewhat unclear, many
doctors recommend that people with high cholesterol reduce their sugar intake.
Coffee
Drinking boiled or French press coffee increases cholesterol levels.77 Modern paper
coffee filters trap the offending chemicals and keep them from entering the cup. Therefore,
drinking paper-filtered coffee does not increase cholesterol levels.78
79 Espresso coffee has amounts of the offending chemicals midway between those of other
unfiltered coffees and paper-filtered coffee,80 but there is little research
investigating the effect of espresso on cholesterol levels, and studies to date have produced
conflicting results.81 82 The effects of decaffeinated coffee on
cholesterol levels remain in debate.83
Alcohol
Moderate drinking (one to two drinks per day) increases protective HDL
cholesterol.84 This effect happens equally with different kinds of
alcohol-containing beverages.85 86 Alcohol also acts as a blood
thinner,87 an effect that should lower heart disease. However, alcohol consumption
may cause liver disease (e.g., cirrhosis), cancer, high blood pressure, alcoholism, and, at high intake, an increased
risk of heart disease. As a result, some
doctors never recommend alcohol, even for people with high cholesterol. Nevertheless, those
who have one to two drinks per day appear to live longer88 and are clearly less
likely to have heart disease.89 Therefore, some people at very high risk of heart
disease—those who are not alcoholics, who have healthy livers and normal blood pressure,
and who are not at high risk for cancer, particularly breast cancer—are likely to receive more benefit
than harm, from light drinking.
Olive
oil
Olive oil lowers LDL cholesterol,90 91 especially when the olive oil
replaces saturated fat in the
diet.92 People from countries that use significant amounts of olive oil appear to
be at low risk for heart disease.93 A double-blind trial showed that a diet high in
monounsaturated fatty acids from olive oil, lowers cardiovascular disease risk by 25%, as
compared with a 12% decrease from a low-fat (25% fat) diet.94 The trial also found
that low-fat diets decrease HDL cholesterol by
4%, which is undesirable, since HDL cholesterol is protective against heart disease. Diets
high in monounsaturated fatty acids from olive oil do not adversely affect HDL levels.
Although olive oil is clearly safe for people with elevated cholesterol, it is, like any fat
or oil, high in calories, so people who are
overweight should limit its use.
Trans fatty acids and
margarine
Trans fatty acids (TFAs) are found in many processed foods containing partially hydrogenated
oils. The highest levels occur in margarine.
Margarine consumption is linked to increased risk of unfavorable changes in cholesterol
levels95 and heart
disease.96 Margarine and other processed foods containing partially
hydrogenated oils should be avoided.
However, special therapeutic margarines are now available that contain substances, called
phytostanols, that block the absorption of cholesterol.97 The FDA has approved some
of these margarines as legitimate therapeutic agents for lowering blood cholesterol levels.
The best-known of these products is Benecol™. The cholesterol-lowering effect of these
margarines has been demonstrated in numerous double-blind and other controlled
trials.98 99 100 101 102 103
104
Garlic
Garlic is available as a food, as a spice in powder form, and as a supplement. Eating garlic
has helped to lower cholesterol in some research,105 though several double-blind
trials have not found garlic supplements to be thusly effective.106 107
108 Although some of the negative reports have been criticized,109 the
relationship between garlic and cholesterol lowering remains unproven.110 However,
garlic is known to act as a blood thinner111 and may reduce other risk factors for
heart disease.112 For these reasons, some doctors recommend eating garlic as food,
taking 900 mg of garlic powder from capsules, or using a tincture of 2 to 4 ml, taken three
times daily.
Nuts
Preliminary research consistently shows that people who eat nuts frequently have a
dramatically reduced risk of heart
disease.113 114 This apparent beneficial effect is at least
partially explained by preliminary and controlled research demonstrating that nut consumption
lowers cholesterol levels.115 116 Of nuts commonly consumed, almonds117 118 and walnuts119 120 121
may be most effective at lowering cholesterol.
Macadamia nuts have been less beneficial in most studies,122 123
124 although one controlled trial found a cholesterol-lowering effect from
macadamia nuts.125
Hazelnuts126 and pistachio
nuts127 have also been reported to help lower cholesterol.
Nuts contain many factors that could be responsible for protection against heart disease,
including fiber, vitamin E, alpha-linolenic acid (found primarily in
walnuts), oleic acid, magnesium, potassium, and arginine. Therefore, exactly how nuts lower
cholesterol or lower the risk of heart disease remains somewhat unclear. Some doctors even
believe that nuts may not be directly protective; rather, people busy eating nuts
will not simultaneously be eating eggs, dairy, or trans fatty acids from margarine and processed food, the avoidance of which
would reduce cholesterol levels and the risk of heart disease.128 129
Nonetheless, the remarkable consistency of research outcomes strongly suggests that nuts do
help protect against heart disease. Although nuts are loaded with calories, a preliminary
trial surprisingly reported that adding hundreds of calories per day from nuts for six months
did not increase body weight in
humans130 —an outcome supported by other reports.131 Even when
increasing nut consumption has led to weight gain, the amount of added weight has been
remarkably less than would be expected, given the number of calories added to the
diet.132 Given the number of calories per ounce of nuts, scientists do not
understand why moderate nut consumption apparently has so little effect on body weight.
Number and size of meals
When people eat a number of small meals, serum cholesterol levels fall compared with the
effect of eating the same food in three big meals.133 134 People with
elevated cholesterol levels should probably avoid very large meals and eat more frequent,
smaller meals.
Vitamins that may be helpful
Glucomannan is a water-soluble dietary fiber that is derived from konjac root.
Controlled154 155 and double-blind156 157 trials
have shown that supplementation with glucomannan significantly reduced total blood
cholesterol, LDL cholesterol, and
triglycerides, and in some cases raised HDL cholesterol. Effective amounts of glucomannan
for lowering blood cholesterol have been 4 to 13 grams per day.
Test tube and animal studies indicate that
policosanol is capable of inhibiting cholesterol production by the liver.158
159 Extensive preliminary and double-blind research in Cuba and other countries in
Latin America has demonstrated that taking 10 to 20 mg per day of policosanol extracted from
sugar cane results in significant changes in blood cholesterol levels, including total
cholesterol (17 to 21% lower on average), LDL cholesterol (21 to 29% lower), and HDL
cholesterol (7 to 29% higher).160 161 162 163
164 165 166 167 168 169
170 However, virtually all of this research was conducted by a single research
group from Cuba. A follow-up double-blind study performed by German scientists found that
sugar cane–derived policosanol in amounts of 10 to 80 mg per day taken for 12 weeks had
no effect on serum cholesterol levels in people with initially high cholesterol
levels.171 Until additional independent studies are performed, the effect of
policosanol on serum cholesterol levels must be considered uncertain.
The combined results of nine double-blind trials indicate that supplementation with beta-hydroxy-beta-methylbutyrate (HMB)
effectively lowers total and LDL cholesterol.172 All trials used 3 grams per day,
taken for three to eight weeks.
Vitamin C appears to protect LDL
cholesterol from damage.173 In some clinical trials, cholesterol levels have fallen
when people with elevated cholesterol supplement with vitamin C.174 Some studies
report that decreases in total cholesterol occur specifically in LDL
cholesterol.175 Doctors sometimes recommend 1 gram per day of vitamin C. A review
of the disparate research concerning vitamin C and heart disease, however, has suggested that most
protection against heart disease from vitamin C, is likely to occur with as little as 100 mg
per day.176
Pantethine, a byproduct of vitamin B5 (pantothenic acid), may help reduce the
amount of cholesterol made by the body. Several preliminary177 178
179 180 181 and two controlled182 183 trials
have found that pantethine (300 mg taken two to four times per day) significantly lowers serum
cholesterol levels and may also increase HDL. However, one double-blind trial in people whose
high blood cholesterol did not change with diet and drug therapy, found that pantethine was
also not effective.184 Common pantothenic acid has not been reported to have any
effect on high blood cholesterol.
Chromium supplementation has reduced total
cholesterol,185 186 LDL cholesterol187 188 and
increased HDL cholesterol189 190 in double-blind and other controlled
trials, although other trials have not found these effects.191 192 One
double-blind trial found that high amounts of chromium (500 mcg per day) in combination with
daily exercise was highly effective, producing nearly a 20% decrease in total cholesterol
levels in just 13 weeks.193
Brewer’s yeast, which contains
readily absorbable and biologically active
chromium, has also lowered serum cholesterol.194 People with higher blood
levels of chromium appear to be at lower risk for heart disease.195 A reasonable
and safe intake of supplemental chromium is 200 mcg per day. People wishing to use
brewer’s yeast as a source of chromium should look for products specifically labeled
“from the brewing process” or “brewer’s yeast,” since most yeast
found in health food stores is not brewer’s yeast, and does not contain chromium.
Optimally, true brewer’s yeast contains up to 60 mcg of chromium per tablespoon, and a
reasonable intake is 2 tablespoons per day.
High amounts (several grams per day) of niacin, a form of vitamin B3, lower cholesterol, an effect recognized in
the approval of niacin as a prescription medication for high cholesterol.196 The
other common form of vitamin B3—niacinamide—does not affect cholesterol levels.
Some niacin preparations have raised HDL cholesterol better than certain prescription
drugs.197 Some cardiologists prescribe 3 grams of niacin per day or even higher
amounts for people with high cholesterol levels. At such intakes, acute symptoms (flushing,
headache, stomachache) and chronic symptoms (liver damage, diabetes,
gastritis, eye damage, possibly gout) of
toxicity may be severe. Many people are not able to continue taking these levels of niacin due
to discomfort or danger to their health. Therefore, high intakes of niacin must only be taken
under the supervision of a doctor.
Symptoms caused by niacin supplements, such as flushing, have been reduced with
sustained-release (also called “time-release”) niacin products. However,
sustained-release forms of niacin have caused significant liver toxicity and, though rarely,
liver failure.198 199 200 201 202 One
partial time-release (intermediate-release) niacin product has lowered LDL cholesterol and
raised HDL cholesterol without flushing, and it also has acted without the liver function
abnormalities typically associated with sustained-release niacin formulations.203
However, this form of niacin is available by prescription only.
In an attempt to avoid the side effects of niacin, alternative health practitioners
increasingly use inositol hexaniacinate,
recommending 500 to 1,000 mg, taken three times per day, instead of niacin.204
205 This special form of niacin has been reported to lower serum cholesterol but so
far has not been found to cause significant toxicity.206 Unfortunately, compared
with niacin, far fewer investigations have studied the possible positive or negative effects
of inositol hexaniacinate. As a result, people using inositol hexaniacinate should not take it
without the supervision of a doctor, who will evaluate whether it is helpful (by measuring
cholesterol levels) and will make sure that toxicity is not occurring (by measuring liver enzymes, uric acid and glucose levels, and by
taking medical history and doing physical examinations).
Soy supplementation has been shown to lower
cholesterol in humans.207 Soy is available in foods such as tofu,
miso, and tempeh and as a supplemental
protein powder. Soy contains isoflavones, naturally occurring plant components that are
believed to be soy’s main cholesterol-lowering ingredients. A controlled trial showed
that soy preparations containing high amounts of isoflavones effectively lowered total
cholesterol and LDL (“bad”) cholesterol, whereas low-isoflavone preparations (less
than 27 mg per day) did not.208 However, supplementation with either
soy209 or non-soy isoflavones (from red clover)210 in pill form failed
to reduce cholesterol levels in a group of healthy volunteers, suggesting that isoflavone may
not be responsible for the cholesterol-lowering effects of soy. Further trials of
isoflavone supplements in people with elevated cholesterol, are needed to resolve these
conflicting results. In a study of people with high cholesterol levels, a soy preparation that
contained soy protein, soy fiber, and soy phospholipids lowered cholesterol levels more
effectively than isolated soy protein.211
Soy contains phytosterols. One such molecule,
beta-sitosterol, is available as a supplement. Beta-sitosterol alone, and in combination
with similar plant sterols, has been shown to reduce blood levels of cholesterol in
preliminary212 and controlled213 214 trials. This effect may
occur because beta-sitosterol blocks absorption of cholesterol.215 In studying the
effects of 0.8, 1.6, and 3.2 grams of plant sterols per day, one double-blind trial found that
higher intake of sterols tended to result in greater reduction in cholesterol, though the
differences between the effects of these three amounts were not statistically
significant.216
A synthetic molecule related to
beta-sitosterol, sitostanol, is available in a special margarine and has also been shown to lower cholesterol
levels. In one controlled trial, supplementation with 1.7 grams per day of a plant-sterol
product containing mostly sitostanol, combined with dietary changes, led to a dramatic 24%
drop in LDL (“bad”) cholesterol compared with only a 9% decrease in the diet-only
part of the trial.217 Other controlled and double-blind trials have confirmed these
results.218 219 220 221 222
223 A review of double-blind trials on sitostanol found that a reduction in the risk of
heart disease of about 25% may be expected
from use of sitostanol-containing spreads, a larger clinical effect than that produced by
people reducing their saturated fat
intake.224 Supplementation with sitostanol in the amount of 1.8 grams per day for
six weeks has also been shown to enhance the cholesterol-lowering effect of statin
drugs.225
Tocotrienols, a group of food-derived
compounds that resemble vitamin E, may lower
blood levels of cholesterol, but evidence is conflicting. Although tocotrienols inhibited
cholesterol synthesis in test-tube studies,226 227 human trials have
produced contradictory results. Two double-blind trials found that 200 mg per day of either
gamma-tocotrienol228 or total tocotrienols229 were more effective than
placebo, reducing cholesterol levels by 13–15%. However, in another double-blind trial,
200 mg of tocotrienols per day failed to lower cholesterol levels,230 and a fourth
double-blind trial found 140 mg of tocotrienols and 80 mg of vitamin E (d-alpha-tocopherol)
daily resulted in no changes in total cholesterol, LDL cholesterol, or HDL cholesterol
levels.231
Deficiency of the trace mineral, copper, has been linked to high blood
cholesterol.232 233 In a controlled trial, daily supplementation with 3
to 4 mg of copper for eight weeks decreased
blood levels of total cholesterol and LDL cholesterol, in a group of people over 50 years of
age.234
Beta-glucan is a type of soluble fiber molecule derived from the cell wall of
baker’s yeast, oats and barley, and many
medicinal mushrooms, such as maitake.
Beta-glucan is the key factor for the cholesterol-lowering effect of oat bran.235
236 237 238 As with other soluble-fiber components, the
binding of cholesterol (and bile acids) by beta-glucan and the resulting elimination of these
substances in the feces is very helpful for reducing blood cholesterol.239
240 241 Results from a number of double-blind trials with either oat- or
yeast-derived beta-glucan indicate typical reductions, after at least four weeks of use, of
approximately 10% for total cholesterol and 8% for LDL (“bad”) cholesterol, with
elevations in HDL (“good”) cholesterol ranging from zero to 16%.242
243 244 245 246 For lowering cholesterol levels,
the amount of beta-glucan used has ranged from 2,900 to 15,000 mg per day.
Some preliminary247 and double-blind248 249 trials have
shown that supplemental calcium reduces
cholesterol levels. Possibly the calcium is binding with and preventing the absorption of
dietary fat.250 However, other research has found no substantial or statistically
significant effects of calcium supplementation on total cholesterol or HDL
(“good”) cholesterol.251 Reasonable supplemental levels are 800 to
1,000 mg per day.
In one double-blind trial,252
vitamin E increased protective HDL cholesterol, but several other trials,253
254 255 found no effect of vitamin E. However, vitamin E is known to
protect LDL cholesterol from damage.256 Most cardiologists believe that only
damaged LDL increases the risk of heart disease. Studies of the ability of vitamin E
supplements to prevent heart disease have
produced conflicting results,257 but many doctors continue to recommend that
everyone supplement 400 IU of vitamin E per day to lessen the risk of having a heart attack.
L-carnitine is needed by heart muscle to
utilize fat for energy. Some,258 259 but not all, preliminary trials
report that carnitine reduces serum cholesterol.260 HDL cholesterol has also
increased in response to carnitine supplementation.261 262 People have
been reported in controlled research to stand a greater chance of surviving a heart attack if
they are given L-carnitine supplements.263 Most trials have used 1 to 4 grams of
carnitine per day.
Magnesium is needed by the heart to
function properly. Although the mechanism is unclear, magnesium supplements (430 mg per day)
lowered cholesterol in a preliminary trial.264 Another preliminary study reported
that magnesium deficiency is associated with a low HDL cholesterol level.265
Intravenous magnesium has reduced death following heart attacks in some, but not all, clinical
trials.266 Though these outcomes would suggest that people with high cholesterol
levels should take magnesium supplements, an isolated double-blind trial reported that people
with a history of heart disease assigned to magnesium supplementation experienced an
increased number of heart attacks.267 More information is necessary before the
scientific community can clearly evaluate the role magnesium should play for people with
elevated cholesterol.
Chondroitin sulfate has lowered serum
cholesterol levels in preliminary trials.268 269 Years ago, this
supplement dramatically reduced the risk of heart attacks in a controlled, six-year follow-up
of people with heart disease.270
The few doctors aware of these older clinical trials sometimes tell people with a history of
heart disease or elevated cholesterol levels, to take approximately 500 mg of chondroitin
sulfate three times per day.
Although lecithin has been reported to
increase HDL cholesterol and lower LDL cholesterol,271 a review of the research
found that the positive effect of lecithin was likely due to the polyunsaturated fat content of the
lecithin.272 If this is so, it would make more sense to use inexpensive vegetable
oil, rather than take lecithin supplements.
However, an animal study found a cholesterol-lowering effect of lecithin independent of its
polyunsaturate content.273 A double-blind trial found that 20 grams of soy lecithin
per day for four weeks had no significant effect on total cholesterol, LDL cholesterol, HDL
cholesterol, or triglycerides.274
Whether taking lecithin supplements is a useful way to lower cholesterol in people with
elevated cholesterol levels remains unclear.
The fiber-like supplement chitosan appears to reduce the absorption of bile
acids or cholesterol; either of these effects may cause a lowering of blood cholesterol.
275 This effect has been repeatedly demonstrated in animals, and a preliminary human
study showed that 3 to 6 grams per day of chitosan taken for two weeks resulted in a 6% drop
in cholesterol and a 10% increase in HDL ("good") cholesterol. 276 Another
preliminary trial showed a 43% lowering of total cholesterol in people being treated for
kidney failure with dialysis who took 4 grams per day of chitosan for 12 weeks. These people
also appeared to have improved kidney function and less severe anemia after chitosan
treatment. 277 In a double-blind trial, however, administration of 2.4 grams of
chitosan per day for three months to people with high cholesterol had no effect on their
cholesterol levels. 278
Chitosan in large amounts, given with vitamin
C, has been shown to reduce dietary fat
absorption in animals fed a high-fat diet. 279 280 281
However, the absorption of minerals and fat-soluble vitamins was also reduced by feeding animals large
amounts of chitosan. 282 In studies in humans, chitosan did not reduce the
absorption of dietary fat.283 284
Royal jelly has prevented the
cholesterol-elevating effect of nicotine285 and has lowered serum cholesterol in
animal studies.286 Preliminary human trials have also found that royal jelly may
lower cholesterol levels.287 288 An analysis of cholesterol-lowering
trials shows that 50 to 100 mg per day is the typical amount used in such
research.289
A double-blind trial found that 20 grams per day of creatine taken for five days, followed by ten grams
per day for 51 days, significantly lowered serum total cholesterol and triglycerides, but did
not change either LDL or HDL cholesterol, in both men and women.290 However,
another double-blind trial found no change in any of these blood levels in trained athletes
using creatine during a 12-week strength training program.291 Creatine
supplementation in this negative trial was lower—only 5 grams per day were taken for the
last 11 weeks of the study.
Octacosanol, a substance found in wheat
germ oil, is sometimes available as a supplement. Small amounts (5 to 20 mg per day) of
policosanol, an experimental supplement from Cuba consisting primarily of octacosanol, has led
to large reductions in LDL cholesterol and/or increases in HDL.292 293
294 295 Octacosanol may lower cholesterol by inhibiting the
liver’s production of cholesterol.296
Homocysteine, a substance linked to heart disease risk, may increase the rate at
which LDL cholesterol is damaged.297 While vitamin B6, vitamin B12, and folic acid lower homocysteine,298 a recent
trial found no effect of supplements of these vitamins on protecting LDL cholesterol, even
though homocysteine was lowered.299
Are there any side effects or interactions?
Refer to the individual supplement for information about any side effects or interactions.
1. Kromhout D, Menotti A, Bloemberg B, et al. Dietary saturated and trans
fatty acids and cholesterol and 25-year mortality from coronary heart disease: the Seven
Countries Study. Prev Med 1995;24:308–15.
2. Tell GS, Evans GW, Folsom AR, et al. Dietary fat intake and carotid
artery wall thickness: the Atherosclerosis Risk in Communities (ARIC) study. Am J
Epidemiol 1994;139:979–89.
3. Ornish D, Brown SE, Scherwitz LW, et al. Can lifestyle changes reverse
coronary heart disease? The Lifestyle Heart Trial. Lancet 1990;336:129–33.
4. Denke MA, Grundy SM. Comparison of effects of lauric acid and palmitic
acid on plasma lipids and lipoproteins. Am J Clin Nutr 1992;56:895–8.
5. Zock PL, de Vries JHM, Katan MB. Impact of myristic acid versus
palmitic acid on serum lipid and lipoprotein levels in healthy women and men. Arterioscler
Thromb 1994;14:567–75.
6. Kumar PD. The role of coconut and coconut oil in coronary heart
disease in Kerala, south India. Trop Doct 1997;27:215–7.
7. Denke MA, Grundy SM. Comparison of effects lof auric acid and palmitic
acid on plasma lipids and lipoproteins. Am J Clin Nutr 1992;56:895–8.
8. Mendis S, Kumarasunderam R. The effect of daily consumption of coconut
fat and soya-bean fat on plasma lipids and lipoproteins of young normolipidaemic men. Br J
Nutr 1990;63:547–52.
9. Dreon DM, Fernstrom HA, Williams PT, Krauss RM. A very-low-fat diet is
not associated with improved lipoprotein profiles in men with a predominance of large,
low-density lipoproteins. Am J Clin Nutr 1999;69:411–8.
10. Hepner G, Fried R, St Jeor S, et al. Hypocholesterolemic effect of
yogurt and milk. Am J Clin Nutr 1979;19–24.
11. Agerholm-Larsen L, Raben A, Haulrik N, et al. Effect of 8 week intake
of probiotic milk products on risk factors for cardiovascular diseases. Eur J Clin
Nutr 2000;54:288–97.
12. Bertolami MC, Faludi AA, Batlouni M. Evaluation of the effects of a
new fermented milk product (Gaio) on primary hypercholesterolemia. Eur J Clin Nutr
1999;53:97–101.
13. Anderson JW, Gilliland SE. Effect of fermented milk (yogurt)
containing Lactobacillus acidophilus L1 on serum cholesterol in hypercholesterolemic humans.
J Am Coll Nutr 1999;18:43–50.
14. Schaafsma G, Meuling WJ, van Dokkum W, Bouley C. Effects of a milk
product, fermented by Lactobacillus acidophilus and with fructo-oligosaccharides added, on
blood lipids in male volunteers. Eur J Clin Nutr 1998;52:436–40.
15. Agerbaek M, Gerdes LU, Richelsen B. Hypocholesterolaemic effect of a
new fermented milk product in healthy middle-aged men. Eur J Clin Nutr
1995;49:346–52.
16. Richelsen B, Kristensen K, Pedersen SB. Long-term (6 months) effect
of a new fermented milk product on the level of plasma lipoproteins—a placebo-controlled
and double blind study. Eur J Clin Nutr 1996;50:811–5.
17. De Roos NM, Schouten G, Katan MB. Yoghurt enriched with
Lactobacillus acidophilus does not lower blood lipids in healthy men and women with
normal to borderline high serum cholesterol levels. Eur J Clin Nutr
1999;53:277–80.
18. Thompson LU, Jenkins DJ, Amer MA, et al. The effect of fermented and
unfermented milks on serum cholesterol. Am J Clin Nutr 1982;36:1106–11.
19. Rossouw JE, Burger EM, Van der Vyver P, Ferreira JJ. The effect of
skim milk, yoghurt, and full cream milk on human serum lipids. Am J Clin Nutr
1981;34:351–6.
20. Santos MJ, Lopez-Jurado M, Llopis J, et al. Influence of dietary
supplementation with fish on plasma total cholesterol and lipoprotein cholesterol fractions in
patients with coronary heart disease. J Nutr Med 1992;3:107–15.
21. Kromhout D, Bosschieter EB, Coulander CD. The inverse relation
between fish consumption and 20-year mortality from coronary heart disease. N Engl J
Med 1985;312:1205–9.
22. Ascherio A, Rimm EG, Stampfer MJ, et al. Dietary intake of marine n-3
fatty acids, fish intake, and the risk of coronary disease among men. N Engl J Med
1995;332:977–82.
23. Albert CM, Manson JE, O’Donnell C, et al. Fish consumption and
the risk of sudden death in the Physicians’ Health Study. Circulation
1996;94(Suppl 1):I–578 [abstract #3382].
24. Thorogood M, Carter R, Benfield L, et al. Plasma lipids and
lipoprotein cholesterol concentrations in people with different diets in Britain. Br Med
J (Clin Res Ed) 1987;295:351–3.
25. Burr ML, Sweetnam PM. Vegetarianism, dietary fiber and mortality.
Am J Clin Nutr 1982;36:873–7.
26. Resnicow K, Barone J, Engle A, et al. Diet and serum lipids in vegan
vegetarians: a model for risk reduction. J Am Dietet Assoc 1991;91:447–53.
27. Ornish D, Brown SE, Scherwitz LW, et al. Can lifestyle changes
reverse coronary heart disease? The Lifestyle Heart Trial. Lancet
1990;336:129–33.
28. Ornish D, Scherwitz LW, Billings JH, et al. Intensive lifestyle
changes for reversal of coronary heart disease. JAMA 1998;280:2001–7.
29. Connor SL, Connor WE. The importance of dietary cholesterol in
coronary heart disease. Prev Med 1983;12:115–23 [review].
30. Edington JD, Geekie M, Carter R, et al. Serum lipid response to
dietary cholesterol in subjects fed a low-fat, high-fiber diet. Am J Clin Nutr
1989;50:58–62.
31. Raloff J. Oxidized lipids: a key to heart disease? Sci News
1985;127:278.
32. Levy Y, Maor I, Presser D, Aviram M. Consumption of eggs with meals
increases the susceptibility of human plasma and low-density lipoprotein to lipid
peroxidation. Ann Nutr Metabol 1996;40:243–51.
33. Shekelle RB, Stamler J. Dietary cholesterol and ischaemic heart
disease. Lancet 1989;i:1177–9.
34. Hu FB, Stampfer MJ, Rimm EB, et al. A prospective study of egg
consumption and risk of cardiovascular disease in men and women. JAMA
1999;281:1387–94.
35. Cox C, Mann J, Sutherland W, et al. Effects of coconut oil, butter,
and safflower oil on lipids and lipoproteins in persons with moderately elevated cholesterol
levels. J Lipid Res 1995;36:1787–95.
36. McKenney JM, Proctor JD, Wright JT et al. The effect of supplemental
dietary fat on plasma cholesterol levels in lovastatin-treated hypercholesterolemic patients.
Pharmacotherapy 1995;15:565–72.
37. Anderson JW, Chen WJL. Legumes and their soluble fiber: effect on
cholesterol-rich lipoproteins. In: Furda I, ed. Unconventional Sources of Dietary
Fiber. Washington, DC: American Chemical Society, 1983.
38. Ripsin CM, Keenan JM, Jacobs DR, et al. Oat products and lipid
lowering—a meta-analysis. JAMA 1992;267:3317–25.
39. Anderson JW, Allgood LD, Lawrence A, et al. Cholesterol-lowering
effects of psyllium intake adjunctive to diet therapy in men and women with
hypercholesterolemia: meta-analysis of 8 controlled trials. Am J Clin Nutr
2000;71:472–9.
40. Miettinen TA, Tarpila S. Effect of pectin on serum cholesterol, fecal
bile acids and biliary lipids in normolipidemic and hyperlipidemic individuals. Clin Chim
Acta 1977;79:471–7.
41. Glore SR, Van Treeck D, Knehans AW, Guild M. Soluble fiber and serum
lipids: a literature review. J Am Dietet Assoc 1994;94:425–36.
42. Romero AL, Romero JE, Galaviz S, Fernandez ML. Cookies enriched with
psyllium or oat bran lower plasma LDL cholesterol in normal and hypercholesterolemic men from
Northern Mexico. J Am Coll Nutr 1998;17:601–8.
43. Rimm EB, Ascherio A, Giovannucci E, et al. Vegetable, fruit, and
cereal fiber intake and risk of coronary heart disease among men. JAMA
1996;275:447–51.
44. Knopp RH, Superko HR, Davidson M, et al. Long-term blood
cholesterol-lowering effects of a dietary fiber supplement. Am J Prev Med
1999;17:18–23.
45. Moreyra AE, Wilson AC, Koraym A. Effect of combining psyllium fiber
with simvastatin in lowering cholesterol. Arch Intern Med 2005;165:1161–6.
46. Lovegrove JA, Clohessy A, Milon H, Williams CM. Modest doses of
beta-glucan do not reduce concentrations of potentially atherogenic lipoproteins. Am J
Clin Nutr 2000;72:49–55.
47. Uusitupa MI, Ruuskanen E, Makinen E, et al. A controlled study on the
effect of beta-glucan-rich oat bran on serum lipids in hypercholesterolemic subjects: relation
to apolipoprotein E phenotype. J Am Coll Nutr 1992;11:651–9.
48. Braaten JT, Wood PJ, Scott FW, et al. Oat beta-glucan reduces blood
cholesterol concentration in hypercholesterolemic subjects. Eur J Clin Nutr
1994;48:465–74.
49. Davidson MH, Dugan LD, Burns JH, et al. The hypocholesterolemic
effects of beta-glucan in oatmeal and oat bran. A dose-controlled study. JAMA
1991;265:1833–9.
50. Onning G, Wallmark A, Persson M, et al. Consumption of oat milk for 5
weeks lowers serum cholesterol and LDL cholesterol in free-living men with moderate
hypercholesterolemia. Ann Nutr Metab 1999;43:301–9.
51. Beer MU, Arrigoni E, Amado R. Effects of oat gum on blood cholesterol
levels in healthy young men. Eur J Clin Nutr 1995;49:517–22.
52. Bierenbaum ML, Reichstein R, Watkins TR. Reducing atherogenic risk in
hyperlipemic humans with flaxseed supplementation: a preliminary report. J Am Coll
Nutr 1993;12:501–4.
53. Cunnane SC, Ganguli S, Menard C, et al. High alpha-linolenic acid
flaxseed (Linum usitatissimum): some nutritional properties in humans. Br J
Nutr 1993;69:443–53.
54. Arjmandi BH, Khan DA, Juma S, et al. Whole flaxseed consumption
lowers serum LDL-cholesterol and lipoprotein(a) concentrations in postmenopausal women.
Nutr Res 1998;18:1203–14.
55. Jenkins DJA, Kendall CWC, Vidgen E, et al. Health aspects of
partially defatted flaxseed, including effects on serum lipids, oxidative measures, and ex
vivo androgen and progestin activity: a controlled crossover trial. Am J Clin Nutr
1999;69:395–402.
56. Kelley DS, Nelson GJ, Love JE, et al. Dietary alpha-linolenic acid
alters tissue fatty acid composition, but not blood lipids, lipoproteins or coagulation status
in humans. Lipids 1993;28:533–7.
57. Chan JK, Bruce VM, McDonald BE. Dietary a-linolenic acid is as
effective as oleic acid and linoleic acid in lowering blood cholesterol in normolipidemic men.
Am J Clin Nutr 1991;53:1230–4.
58. Pang D, Allman-Farinelli MA, Wong T, et al. Replacement of linoleic
acid with alpha-linolenic acid does not alter blood lipids in normolipidaemic men. Br J
Nutr 1998;80:163–7.
59. Mantzioris E, James MJ, Bibson RA, Cleland LG. Dietary substitution
with an alpha-linolenic acid-rich vegetable oil increases eicosapentaenoic acid concentrations
in tissues. Am J Clin Nutr 1994;59:1304–9.
60. Layne KS, Goh YK, Jumpsen JA, et al. Normal subjects consuming
physiological levels of 18:3(n-3) and 20:5(n-3) from flaxseed or fish oils have characteristic
differences in plasma lipid and lipoprotein fatty acid levels. J Nutr
1996;126:2130–40.
61. De Lorgeril M, Renaud S, Mamelle N, et al. Mediterranean
alpha-linolenic-rich diet in secondary prevention of coronary heart disease. Lancet
1994;343:1454–9.
62. De Lorgeril M, Salen P, Martin J-L, et al. Mediterranean diet,
traditional risk factors, and the rate of cardiovascular complications after myocardial
infarction. Final report of the Lyon Diety Heart Study. Circulation
1999;99:779–85.
63. Rice RD. Mediterranean diet. Lancet 1994;344:893–4
[letter].
64. Anderson JW, Johnstone BM, Cook-Newell ME. Meta-analysis of the
effects of soy protein intake on serum lipids. N Engl J Med
1995;3333:276–82.
65. Sirtori CR, Pazzucconi F, Colombo L, et al. Double-blind study of the
addition of high-protein soya milk v. cows’ milk to the diet of patients with severe
hypercholesterolaemia and resistance to or intolerance of statins. Br J Nutr
1999;82:91–6.
66. Teixeira SR, Potter SM, Weigel R, et al. Effects of feeding 4 levels
of soy protein for 3 and 6 wk on blood lipids and apolipoproteins in moderately
hypercholesterolemic men. Am J Clin Nutr 2000;71:1077–84.
67. Baum JA, Teng H, Erdman JW Jr, et al. Long-term intake of soy protein
improves blood lipid profiles and increases mononuclear cell low-density-lipoprotein receptor
messenger RNA in hypercholesterolemic, postmenopausal women. Am J Clin Nutr
1998;68:545–51.
68. Crouse JR 3rd, Morgan T, Terry JG, et al. A randomized trial
comparing the effect of casein with that of soy protein containing varying amounts of
isoflavones on plasma concentrations of lipids and lipoproteins. Arch Intern Med
1999;159:2070–6.
69. Teixeira SR, Potter SM, Weigel R, et al. Effects of feeding 4 levels
of soy protein for 3 and 6 wk on blood lipids and apolipoproteins in moderately
hypercholesterolemic men. Am J Clin Nutr 2000;71:1077–84.
70. Potter SM, Baum JA, Teng H, et al. Soy protein and isoflavones: their
effects on blood lipids and bone density in postmenopausal women. Am J Clin Nutr
1998;68:1375–79S.
71. Crouse JR 3rd, Morgan T, Terry JG, et al. A randomized trial
comparing the effect of casein with that of soy protein containing varying amounts of
isoflavones on plasma concentrations of lipids and lipoproteins. Arch Intern Med
1999;159:2070–6.
72. Greaves KA, Parks JS, Williams JK, Wagner JD. Intact dietary soy
protein, but not adding an isoflavone-rich soy extract to casein, improves plasma lipids in
ovariectomized cynomolgus monkeys. J Nutr 1999;129:1585–92.
73. Greaves KA, Wilson MD, Rudel LL, et al. Consumption of soy protein
reduces cholesterol absorption compared to casein protein alone or supplemented with an
isoflavone extract or conjugated equine estrogen in ovariectomized cynomolgus monkeys. J
Nutr 2000;130:820–6.
74. Yudkin J, Kang SS, Bruckdorfer KR. Effects of high dietary sugar.
Br Med J 1980;281:1396.
75. Reiser S. Effect of dietary sugars on metabolic risk factors
associated with heart disease. Nutr Health 1985;3:203–16.
76. Liu K, Stamler J, Trevisan M, Moss D. Dietary lipids, sugar, fiber,
and mortality from coronary heart disease. Bivariate analysis of international data.
Arteriosclerosis 1982;2:221–7.
77. Urgert R, Schulz AG, Katan MB. Effects of cafestol and kahweol from
coffee grounds on serum lipids and serum liver enzymes in humans. Am J Clin Nutr
1995;61:149–54.
78. Superko HR, Bortz WM, Albers JJ, Wood PJ. Lipoprotein and
apolipoprotein changes during a controlled trial of caffeinated and decaffeinated coffee
drinking in men. Circulation 1989;80:II–86.
79. Nygärd O, Refsum H, Velanb PM, et al. Coffee consumption and
plasma total homocysteine: the Hordaland Homocysteine Study. Am J Clin Nutr
1997;65:136–43.
80. Gross G, Jaccaud E, Huggett AC. Analysis of the content of the
diterpenes cafestol and kahweol in coffee brews. Food Chem Toxicol
1997;35:547–54.
81. D’Amicis A, Scaccini C, Tomassi G, et al. Italian style brewed
coffee: effect on serum cholesterol in young men. Int J Epidemiol
1996;25:513–20.
82. D’Avanzo B, Santoro L, Nobill A, La Vecchia C. Coffee
consumption and serum cholesterol. GISSI-EFRIM Study Group. Prev Med
1993;22:219–24.
83. [No authors listed.] Regular or decaf? Coffee consumption and serum
lipoproteins. Nutr Rev 1992;50:175–8 [review].
84. Dai WS, Laporte RE, Hom DL, et al. Alcohol consumption and high
density lipoprotein cholesterol concentration among alcoholics. Am J Epidemiol
1985;122:620–7.
85. Marques-Vidal P, Ducimetiere P, Evans A, et al. Alcohol consumption
and myocardial infarction: a case-control study in France and northern Ireland. Am J
Epidemiol 1996;143:1089–93.
86. Rimm EB, Klatsky A, Grobbee D, Stampfer MJ. Review of moderate
alcohol consumption and reduced risk of coronary heart disease: is the effect due to beer,
wine, or spirits? BMJ 1996;312:731–6 [review].
87. Hendriks HF, Veenstra J, Velthuis-te Wierik EJ, et al. Effect of
moderate dose of alcohol with evening meal on fibrinolytic factors. BMJ
1994;304:1003–6.
88. Doll R, Peto AR, Hall E, et al. Mortality in relation to consumption
of alcohol: 13 years’ observations on male British doctors. BMJ
1994;309:911–8.
89. Hein HO, Suadicani P, Gyntelberg F. Alcohol consumption, serum low
density lipoprotein cholesterol concentration, and risk of ischaemic heart disease: six year
follow up in the Copenhagen male study. BMJ 1996;736–41.
90. Baggio G, Pagnan A, Muraca M, et al. Olive-oil-enriched diet: effect
on serum lipoprotein levels and biliary cholesterol saturation. Am J Clin Nutr
1988;47:960–4.
91. Kris-Etherton PM, Pearson TA, Wan Y, et al. High-monounsaturated
fatty acid diets lower both plasma cholesterol and triacylglycerol concentrations. Am J
Clin Nutr 1999;70:1009–15.
92. Grundy SM. Monounsaturated fatty acids and cholesterol metabolism:
implications for dietary recommendations. J Nutr 1989;119:529–33 [review].
93. Keys A, ed. Coronary heart disease in seven countries.
Circulation 1970;41(Suppl Q):I1–211.
94. Kris-Etherton PM, Pearson TA, Wan Y, et al. High-monounsaturated
fatty acid diets lower both plasma cholesterol and triacylglycerol concentrations. Am J
Clin Nutr 1999;70:1009–15.
95. Lichtenstein AH, Ausman LM, Jalbert SM, Schaefer EJ. Effects of
different forms of dietary hydrogenated fats on serum lipoprotein cholesterol levels. N
Engl J Med 1999;340:1933–40.
96. Willett WC, Stampfer MJ, Manson JE, et al. Intake of trans
fatty acids and risk of coronary heart disease among women. Lancet
1993;341:581–5.
97. Normén L, Dutta P, Lia Å, Andersson H. Soy sterol esters
and beta-sitostanol ester as inhibitors of cholesterol absorption in human small bowel. Am
J Clin Nutr 2000;71:908–13.
98. Gylling H, Miettinen TA. Cholesterol reduction by different plant
stanol mixtures and with variable fat intake. Metabolism 1999;48:575–80.
99. Blair SN, Capuzzi DM, Gottlieb SO, et al. Incremental reduction of
serum total cholesterol and low-density lipoprotein cholesterol with the addition of plant
stanol ester-containing spread to statin therapy. Am J Cardiol
2000;86:46–52.
100. Jones PJ, Raeini-Sarjaz M, Ntanios FY, et al. Modulation of plasma
lipid levels and cholesterol kinetics by phytosterol versus phytostanol esters. J Lipid
Res 2000;41:697–705.
101. Hallikainen MA, Sarkkinen ES, Uusitupa MI. Plant stanol esters
affect serum cholesterol concentrations of hypercholesterolemic men and women in a
dose-dependent manner. J Nutr 2000;130:767–76.
102. Vuorio AF, Gylling H, Turtola H, et al. Stanol ester margarine alone
and with simvastatin lowers serum cholesterol in families with familial hypercholesterolemia
caused by the FH-North Karelia mutation. Arterioscler Thromb Vasc Biol
2000;20:500–6.
103. Nguyen TT, Dale LC, von Bergmann K, Croghan IT. Cholesterol-lowering
effect of stanol ester in a US population of mildly hypercholesterolemic men and women: a
randomized controlled trial. Mayo Clin Proc 1999;74:1198–206.
104. Moghadasian MH, Frohlich JJ. Effects of dietary phytosterols on
cholesterol metabolism and atherosclerosis: clinical and experimental evidence. Am J
Med 1999;107:588–94 [review].
105. Warshafsky S, Kamer RS, Sivak SL. Effect of garlic on total serum
cholesterol—a meta-analysis. Ann Intern Med 1993;119:599–605.
106. McCrindle BW, Helden E, Conner WT. Garlic extract therapy in
children with hypercholesterolemia. Arch Pediatr Adolesc Med
1998;152:1089–94.
107. Isaacsohn JL, Moser M, Stein EA, et al. Garlic powder and plasma
lipids and lipoproteins. Arch Intern Med 1998;158:1189–94.
108. Berthold HK, Sudhop T, von Bergmann K. Effect of a garlic oil
preparation on serum lipoproteins and cholesterol metabolism. JAMA
1998;279:1900–2.
109. Lawson L. Garlic oil for hypercholesterolemia—negative
results. Quart Rev Natural Med Fall 1998;185–6.
110. Lawson LD. Garlic powder for hyperlipidemia—analysis of recent
negative results. Quart Rev Natural Med 1998;Fall:187–9.
111. Lawson LD, Ransom DK, Hughes BG. Inhibition of whole blood
platelet-aggregation by compounds in garlic clove extracts and commercial garlic products.
Thrombosis Res 1992;65:141–56.
112. Mansell P, Reckless JP. Garlic—effects on serum lipids, blood
pressure, coagulation, platelet aggregation, and vasodilatation. BMJ
1991;303:379–80 [editorial].
113. Hu FB, Stampfer MJ, Manson JE, et al. Frequent nut consumption and
risk of coronary heart disease in women: prospective cohort study. BMJ
1998;317:1341–5.
114. Fraser GE, Sabaté J, Beeson WL, Strahan TM. A possible
protective effect of nut consumption on risk of coronary heart disease. Arch Intern
Med 1992;152:1416–24.
115. Abbey M, Noakes M, Belling GB, Nestel PJ. Partial replacement of
saturated fatty acids with almonds or walnuts lowers total plasma cholesterol and
low-density-lipoprotein cholesterol. Am J Clin Nutr 1994;59:995–9.
116. Hu FB, Stampfer MJ. Nut consumption and risk of coronary heart
disease: a review of epidemiologic evidence. Curr Atheroscler Rep
1999;1:204–9.
117. Spiller GA, Jenkins DA, Bosello O, et al. Nuts and plasma lipids: an
almond-based diet lowers LDL-C while preserving HDL-C. J Am Coll Nutr
1998;17:285–90.
118. Spiller GA, Jenkins DJ, Cragen LN, et al. Effect of a diet high in
monounsaturated fat from almonds on plasma cholesterol and lipoproteins. J Am Coll
Nutr 1992;11:126–30.
119. Sabaté J, Fraser GE, Burke K, et al. Effects of walnuts on
serum lipid levels and blood pressure in normal men. N Engl J Med
1993;328:603–7.
120. Zambon D, Campero B, Perez-Heras A, et al. Effects of walnuts on the
serum lipid profile of hypercholesterolemic subjects: the Barcelona Walnut Trial. FASEB
J 1998;12:A506 [abstract].
121. Zambon D, Sabate J, Munoz S, et al. Substituting walnuts for
monounsaturated fat improves the serum lipid profile of hypercholesterolemic men and women. A
randomized crossover trial. Ann Intern Med 2000;132:538–46.
122. Colquhoun D, Moores D, Humphries J, Somerset S. Comparison of a high
monounsaturated fatty acid diet (enriched with macadamia nut) and a high carbohydrate diet on
blood lipids [abstract]. Proceedings of the 59th European Atherosclerosis Congress.
Nice, France: May 1992, 17–21.
123. Curb JD, Wergowski G, Abbott RD, et al. High mono-unsaturated fat
macadamia nut diets: effects on serum lipids and lipoproteins. FASEB J 1998;12:A506
[abstract].
124. Fraser GE. Nut consumption, lipids, and risk of a coronary event.
Clin Cardiol 1999;22(7 Suppl):III11–5 [review].
125. Curb JD, Wergowske G, Dobbs JC, et al. Serum lipid effects of a
high-monounsaturated fat diet based on macadamia nuts. Arch Intern Med
2000;160:1154–8.
126. Durak I, Köksal I, Kaçmaz M, et al. Hazelnut
supplementation enhances plasma antioxidant potential and lowers plasma cholesterol levels.
Clin Chim Actia 1999;284:113–5 [letter].
127. Edwards K, Kwaw I, Matud J, Kurtz I. Effect of pistachio nuts on
serum lipid levels in patients with moderate hypercholesterolemia. J Am Coll Nutr
1999;18:229–32.
128. Mirkin G. Walnuts and serum lipids. N Engl J Med
1993;329:358 [letter].
129. Mann GV. Walnuts and serum lipids. N Engl J Med
1993;329:358 [letter].
130. Fraser GE, Jaceldo K, Sabaté J, et al. Changes in body weight
with a daily supplement of 340 calories from almonds for six months. FASEB J
1999;13:A539 [abstract].
131. Fraser GE. Nut consumption, lipids, and risk of a coronary event.
Clin Cardiol 1999;22(7 Suppl):III11–5 [review].
132. Durak I, Köksal I, Kaçmaz M, et al. Hazelnut
supplementation enhances plasma antioxidant potential and lowers plasma cholesterol levels.
Clin Chim Actia 1999;284:113–5 [letter].
133. Jenkins DJA, Khan A, Jenkins AL, et al. Effect of nibbling versus
gorging on cardiovascular risk factors: serum uric acid and blood lipids. Metabolism
1995;44:549–55.
134. Edelstein SL, Barrett-Connor EL, Wingard DL, Cohn BA. Increased meal
frequency associated with decreased cholesterol concentrations; Rancho Bernardo, CA,
1984–1987. Am J Clin Nutr 1992;55:664–9.
135. Reaven PD, McPhillips JB, Barrett-Connor EL, Criqui MH. Leisure time
exercise and lipid and lipoprotein levels in an older population. J Am Geriatr Soc
1990;38:847–54.
136. Duncan JJ, Gordon NF, Scott CB. Women walking for health and
fitness—how much is enough? JAMA 1991;266:3295–9.
137. Tran ZV, Weltman A. Differential effects of exercise on serum lipid
and lipoprotein levels seen with changes in body weight: a meta-analysis. JAMA
1985;254:919–24.
138. Pekkanen J, Marti B, Nissinen A, Tuomilehto J. Reduction of
premature mortality by high physical activity: a 20-year follow-up of middle-aged Finnish men.
Lancet 1987;1:1473–7.
139. Willich SN, Lewis M, Lowel H, et al. Physical exertion as a trigger
of acute myocardial infarction. N Engl J Med 1993;329:1684–90.
140. Hubert HB, Feinleib M, McNamara PM, Castelli WP. Obesity as an
independent risk factor for cardiovascular disease: a 26-year follow-up of participants in the
Framingham Heart Study. Circulation 1983;67:968–77.
141. Glueck CJ, Taylor HL, Jacobs D, et al. Plasma high-density
lipoprotein cholesterol: association with measurements of body mass: the Lipid Research
Clinics Program Prevalence Study. Circulation 1980;62(Suppl IV):IV62–9.
142. Di Buono M, Hannah JS, Katzel LI, Jones PJH. Weight loss due to
energy restriction suppresses cholesterol bioshynthesis in overweight, mildly
hypercholesterolemic men. J Nutr 1999;129:1545–8.
143. Wood PD, Stefanick ML, Dreon DM, et al. Changes in plasma lipids and
lipoproteins in overweight men during weight loss through dieting as compared with exercise.
N Engl J Med 1988;319:1173–9.
144. Dwyer JH, Rieger-Ndakorerwa GE, Semmer NK, et al. Low-level
cigarette smoking and longitudinal change in serum cholesterol among adolescents.
JAMA 1988;2857–62.
145. Khosla S, Laddu A, Ehrenpreis S, Somberg JC. Cardiovascular effects
of nicotine: relation to deleterious effects of cigarette smoking. Am Heart J
1994;127:1669–71 [editorial/review].
146. Nyboe J, Jensen G, Appleyard M, Schnohr P. Smoking and the risk of
first acute myocardial infarction. Am Heart J 1991;122:438.
147. Kawachi I, Sparrow D, Spiro A, et al. A prospective study of anger
and coronary heart disease. Circulation 1996;94:2090–5.
148. Jiang W, Babyak M, Krantz DS, et al. Mental stress-induced
myocardial ischemia and cardiac events. JAMA 1996;275:1651–6.
149. Bower B. Women take un-type A behavior to heart. Sci News
1993;144:244.
150. Dimsdale, JE. A perspective on type A behavior and coronary disease.
N Engl J Med 1988;318:110–2 [editorial/review].
151. McCann BS, Warnick R, Knopp RH. Changes in plasma lipids and dietary
intake accompanying shifts in perceived workload and stress. Psychosomatic Med
1990;52:97–108.
152. Lundberg U, Hedman M, Melin B, Frankenhaeuser M. Type A Behavior in
healthy males and females as related to physiological reactivity and blood lipids.
Psychosomatic Med 1989;51:113–22.
153. Friedman M, Theresen CE, Gill JJ, et al. Alteration of type A
behavior and reduction in cardiac recurrences in postmyocardial infarction patients. Am
Heart J 1984;108:237–48.
154. Vuksan V, Jenkins DJ, Spadafora P, et al. Konjac-mannan
(glucomannan) improves glycemia and other associated risk factors for coronary heart disease
in type 2 diabetes. A randomized controlled metabolic trial. Diabetes Care
1999;22:913–9.
155. Zhang MY, Huang CY, Wang X, et al. The effect of foods containing
refined Konjac meal on human lipid metabolism. Biomed Environ Sci
1990;3:99–105.
156. Arvill A, Bodin L. Effect of short-term ingestion of konjac
glucomannan on serum cholesterol in healthy men. Am J Clin Nutr
1995;61:585–9.
157. Walsh DE, Yaghoubian V, Behforooz A. Effect of glucomannan on obese
patients: a clinical study. Int J Obes 1984;8:289–93.
158. Menendez R, Arruzazabala L, Más R, et al. Cholesterol-lowering
effect of policosanol on rabbits with hypercholesterolaemia induced by a wheat starch-casein
diet. Br J Nutr 1997;77:923–32.
159. Gouni-Berthold I, Berthold HK. Policosanol: clinical pharmacology
and therapeutic significance of a new lipid-lowering agent. Am Heart J
2002;143:356–65 [review].
160. Gouni-Berthold I, Berthold HK. Policosanol: clinical pharmacology
and therapeutic significance of a new lipid-lowering agent. Am Heart
J2002;143:356–65 [review].
161. Mirkin A, Mas R, Martinto M, et al. Efficacy and tolerability of
policosanol in hypercholesterolemic postmenopausal women. Int J Clin Pharmacol Res
2001;21:31–41.
162. Castano G, Mas R, Fernandez JC, et al. Effects of policosanol in
older patients with type II hypercholesterolemia and high coronary risk. J Gerontol A Biol
Sci Med Sci 2001;56:M186–92.
163. Castano G, Mas R, Fernandez L et al. Effects of policosanol 20
versus 40 mg/day in the treatment of patients with type II hypercholesterolemia: A 6-month
double-blind study. Int J Clin Pharmacol Res 2001;21:43–57.
164. Aneiros E, Calderon B, Más R, et al. Effect of successive dose
increases of policosanol on the lipid profile and tolerability of treatment. Curr Thera
Res1993;54:304–12.
165. Pons P, Rodríquez M, Más R, et al. One-year efficacy and
safety of policosanol in patients with type II hypercholesterolemia. Curr Thera Res
1994;55:1084–92.
166. Castano G, Canetti M, Moreira M, et al. Efficacy and tolerability of
policosanol in elderly patients with type II hypercholesterolemia: a 12-month study. Curr
Thera Res 1995;56:819–28.
167. Castano G, Tula L, Canetti M, et al. Effects of policosanol in
hypertensive patients with type II hypercholesterolemia. Curr Thera Res
1996;57:691–9.
168. Mas R, Castano G, Illnait J, et al. Effects of policosanol in
patients with type II hypercholesterolemia and additional coronary risk factors. Clin
Pharmacol Ther 1999;65:439–47.
169. Torres O, Agramonte AJ, Illnait J, et al. Treatment of
hypercholesterolemia in NIDDM with policosanol. Diabetes Care
1995;18:393–7.
170. Canetti M, Moreira M, Mas R, et al. A two-year study on the efficacy
and tolerability of policosanol in patients with type II hyperlipoproteinaemia. Int J Clin
Pharmacol Res 1995;15:159–65.
171. Berthold HK, Unverdorben S, Degenhardt R, et al. Effect of
policosanol on lipid levels among patients with hypercholesterolemia or combined
hyperlipidemia: a randomized controlled trial. JAMA 2006;295:2262–9.
172. Nissen S, Sharp RL, Panton L, et al.
ß-hydroxy-ß-methylbutyrate (HMB) supplementation in humans is safe and may decrease
cardiovascular risk factors. J Nutr 2000;130:1937–45.
173. Frei B. Ascorbic acid protects lipids in human plasma and
low-density lipoprotein against oxidative damage. Am J Clin Nutr
1991;54:1113–8S.
174. Simon JA. Vitamin C and cardiovascular disease: a review. J Am
Coll Nutr 1992;11:107–27.
175. Gatto LM, Hallen GK, Brown AJ, Samman S. Ascorbic acid induces a
favorable lipoprotein profile in women. J Am Coll Nutr 1996;15;154–8.
176. Balz F. Antioxidant Vitamins and Heart Disease. Presented at the
60th Annual Biology Colloquium, Oregon State University, February 25, 1999.
177. Galeone F, Scalabrino A, Giuntoli F, et al. The lipid-lowering
effect of pantethine in hyperlipidemic patients: a clinical investigation. Curr Ther
Res 1983;34:383–90.
178. Miccoli R, Marchetti P, Sampietro T, et al. Effects of pantethine on
lipids and apolipoproteins in hypercholesterolemic diabetic and non diabetic patients.
Curr Ther Res 1984;36:545–9.
179. Avogaro P, Bon B, Fusello M. Effect of pantethine on lipids,
lipoproteins and apolipoproteins in man. Curr Ther Res 1983;33;488–93.
180. Coronel F, Tornero F, Torrente J, et al. Treatment of hyperlipemia
in diabetic patients on dialysis with a physiological substance. Am J Nephrol
1991;11:32–6.
181. Arsenio L, Bodria P, Magnati G, et al. Effectiveness of long-term
treatment with pantethine in patients with dyslipidemia. Clin Ther
1986;8:537–45.
182. Prisco D, Rogasi PG, Matucci M, et al. Effect of oral treatment with
pantethine on platelet and plasma phospholipids in IIa hyperlipoproteinemia.
Angiology 1987;38:241–7.
183. Gaddi A, Descovich GC, Noseda G, et al. Controlled evaluation of
pantethine, a natural hypolipidemic compound, in patients with different forms of
hyperlipoproteinemia. Atherosclerosis 1984;50:73–83.
184. Da Col PG, et al. Pantethine in the treatment of
hyper-cholesterolemia: a randomized double-blind trial versus tiadenol. Curr Ther Res
1984;36:314.
185. Anderson RA, Cheng N, Bryden NA, et al. Elevated intakes of
supplemental chromium improve glucose and insulin variables in individuals with type 2
diabetes. Diabetes 1997;46:1786–91.
186. Offenbacher EG, Pi-Sunyer FX. Beneficial effect of chromium-rich
yeast on glucose tolerance and blood lipids in elderly subjects. Diabetes
1980;29:919–25.
187. Press RI, Geller J, Evans GW. The effect of chromium picolinate on
serum cholesterol and apolipoprotein fractions in human subjects. West J Med
1990;152:41–5.
188. Hermann J, Chung H, Arquitt A, et al. Effects of chromium or copper
supplementation on plasma lipids, plasma glucose and serum insulin in adults over age fifty.
J Nutr Elderly 1998;18:27–45.
189. Riales R, Albrink MJ. Effect of chromium chloride supplementation on
glucose tolerance and serum lipids including high-density lipoprotein of adult men. Am J
Clin Nutr 1981;34:2670–8.
190. Roeback JR, Hla KM, Chambless LE, Fletcher RH. Effects of chromium
supplementation on serum high-density lipoprotein cholesterol levels in men taking
beta-blockers. Ann Intern Med 1991;115:917–24.
191. Uusitupa MI, Kumpulainen JT, Voutilainen E, et al. Effect of
inorganic chromium supplementation on glucose tolerance, insulin response, and serum lipids in
noninsulin-dependent diabetics. Am J Clin Nutr 1983;38:404–10.
192. Uusitupa MI, Mykkanen L, Siitonen O, et al. Chromium supplementation
in impaired glucose tolerance of elderly: effects on blood glucose, plasma insulin, C-peptide
and lipid levels. Br J Nutr 1992;68:209–16.
193. Boyd SG, Boone BE, Smith AR, et al. Combined dietary chromium
picolinate supplementation and an exercise program leads to a reduction of serum cholesterol
and insulin in college-aged subjects. J Nutr Biochem 1998;9:471–5.
194. Wang MM, Fox EA, Stoecker BJ, et al. Serum cholesterol of adults
supplemented with brewer’s yeast or chromium chloride. Nutr Res
1989;9:989–98.
195. Newman HA, Leighton RF, Lanese RR, Freedland NA. Serum chromium and
angiographically determined coronary artery disease. Clin Chem 1978;541–4.
196. Brown WV. Niacin for lipid disorders. Postgrad Med
1995;98:185–93 [review].
197. Guyton JR, Blazing MA, Hagar J, et al. Extended-release niacin vs
gemfibrozil for the treatment of low levels of high-density lipoprotein cholesterol.
Niaspan-Gemfibrozil Study Group. Arch Intern Med 2000;160:1177–84.
198. McKenney JM, Proctor JD, Harris S, Chinchili VM. A comparison of the
efficacy and toxic effects of sustained- vs immediate-release niacin in hypercholesterolemic
patients. JAMA 1994;271:672–7.
199. Knopp RH, Ginsberg J, Albers JJ, et al. Contrasting effects of
unmodified and time-release forms of niacin on lipoproteins in hyperlipidemic subjects: clues
to mechanism of action of niacin. Metabolism 1985;34:642–50.
200. Gray DR, Morgan T, Chretien SD, Kashyap ML. Efficacy and safety of
controlled-release niacin in dyslipoproteinemic veterans. Ann Intern Med
1994;121:252–8.
201. Rader JI, Calvert RJ, Hathcock JN. Hepatic toxicity of unmodified
and time-release preparations of niacin. Am J Med 1992;92:77–81 [review].
202. Knopp RH. Niacin and hepatic failure. Ann Intern Med
1989;111:769 [letter].
203. Goldberg A, Alagona P Jr, Capuzzi DM, et al. Multiple-dose efficacy
and safety of an extended-release form of niacin in the management of hyperlipidemia. Am J
Cardiol 2000;85:1100–5.
204. Head KA. Inositol hexaniacinate: a safer alternative to niacin.
Alt Med Rev 1996;1:176–84 [review].
205. Murray M. Lipid-lowering drugs vs. Inositol hexaniacinate. Am J
Natural Med 1995;2:9–12 [review].
206. Dorner Von G, Fisher FW. Zur Beinflussung der Serumlipide
und-lipoproteine durch den Hexanicotinsaureester des m-Inositol. Arzneimittel
Forschung 1961;11:110–3.
207. Carrol KK, Kurowska EM. Soy consumption and cholesterol reduction:
review of animal and human studies. J Nutr 1995;125:594–7S.
208. Crouse JR 3rd, Morgan T, Terry JG, et al. A randomized trial
comparing the effect of casein with that of soy protein containing varying amounts of
isoflavones on plasma concentrations of lipids and lipoproteins. Arch Intern Med
1999;159:2070–6.
<