Lifestyle Changes:

The absolute mandate for improving cholesterol levels is to first make changes in lifestyle (both diet and exercise). Even when drugs are used, healthy diet and physical activity are critical companions.

Heart-Healthy Diets

There are many major dietary approaches for protecting health, such as the Mediterranean diet, which emphasizes fruits, vegetables, and healthy types of fats. Doctors generally agree on the following recommendations for heart protection:

• Choose fiber-rich food (whole grains, legumes, and nuts) as the main source of carbohydrates, along with a high intake of fruits and vegetables. Walnuts in particular have cholesterol-lowering properties and are a good source of antioxidants and alpha-linolenic acid.
• Avoid saturated fats (found mostly in animal products) and trans fatty acids (found in hydrogenated fats and many commercial products and fast foods). Choose unsaturated fats (particularly omega-3 fatty acids found in vegetable and fish oils). For dairy products, choose low fat over high fat.
• For proteins, choose soy protein, poultry, and fish over meat. Studies have found that soy does not help improve cholesterol. However, it is still a heart healthy food choice.
• Fish is particularly heart protective. People who don't or won't eat fish can take a daily fish oil supplement. Omega-3 fatty acid fish oil supplements contain docasahexaenoic (DHA) and eicosapentaenoic (EPA) acids, which have significant benefits for the heart, particularly for lowering triglyceride levels. Fish oil supplements are also available in prescription form (Lovaza).
• Controlling weight, quitting smoking, and exercising are essential companions of any diet program.

After embarking on any heart healthy diet, it generally takes an average of 3 - 6 months before any noticeable reduction in cholesterol occurs. However, some people see improved levels in as few as 4 weeks. An intensive program may be necessary to achieve significant improvements in cholesterol levels and to reduce heart risk factors.

[For more information, see In-Depth Report #43: Heart-healthy diet.]

Exercise

Inactivity is one of the four major risk factors for coronary artery disease, on par with smoking, unhealthy cholesterol, and high blood pressure. In fact, studies suggest that people who change their diet in order to control cholesterol only achieve a lower risk for heart disease when they also follow a regular aerobic exercise program.

• People with an active lifestyle have a 45% lower risk of developing heart disease than sedentary people. Physically active people tend to have higher HDL (“good” cholesterol) levels. Research suggests that regular aerobic exercise can help increase HDL levels. Even moderate exercise reduces the risk of heart attack and stroke.
• Resistance (weight) training offers a complementary benefit to aerobics.

Quitting Smoking

Cigarette smoking lowers HDL and is directly responsible for about 20% of all deaths from heart disease. The importance of breaking this habit cannot be emphasized enough. Once a person quits smoking, HDL cholesterol levels rise within weeks or months to levels that are equal to their nonsmoking peers. Passive smoking also reduces HDL levels and increases the risk of heart disease in people exposed to second-hand smoke.

Alcohol

A number of studies have found heart protection from moderate intake of alcohol (one or two glasses a day). Moderate amounts of alcohol help raise HDL levels. Although red wine is most often cited for healthful properties, any type of alcoholic beverage appears to have similar benefit. Pregnant women, anyone who cannot drink moderately, and people with liver disease should not drink at all.

Herbs and Supplements

Manufacturers of herbal remedies and dietary supplements do not need FDA approval to sell their products. Just like a drug, herbs and supplements can affect the body's chemistry, and therefore have the potential to produce side effects that may be harmful. There have been a number of reported cases of serious and even lethal side effects from herbal products. Always check with your doctor before using any herbal remedies or dietary supplements.

The following natural remedies are of interest for cholesterol control:

• Garlic. Contrary to popular belief, neither raw garlic nor garlic supplements significantly reduce LDL cholesterol levels.
• Policosonol. Policosanol is a nutritional supplement derived from sugar cane that has been promoted as having lipid-lowering benefits. However, rigorous research has not shown that policosanol has any effect on reducing LDL levels.
• Red Yeast Rice. Red yeast rice is used in traditional Chinese medicine. The FDA warns that many red yeast rice dietary supplement products sold as treatments for high cholesterol contain prescription drugs that can cause serious health problems.