Less saturated fat, more exercise. Less of the American-style diet, more of the Mediterranean. More fruit, vegetables and fibre, fewer supersize meal deals. These, of course, are the basics of cholesterol-lowering, the fundamental rules for preventing the rise in sticky blood fats to which our generation is so prone. Most of us can reel off the advice, but, it seems, rarely do we heed it.
Although the recommended target level for cholesterol in the UK stands at less than 5 millimoles per litre, men in England have an average level of 5.5 mml/litre and women 5.6. Every year in Britain, one in four men and one in six women who die are killed by coronary heart disease — a total of 105,000 people annually — and nearly half of these deaths are due to raised cholesterol levels. Increasingly, cholesterol-lowering statin drugs are prescribed to those at risk, but could a “portfolio” of carefully selected superfoods be the answer?
In a study published in the American Journal of Clinical Nutrition in March, Professor David Jenkins and a team at the University of Toronto’s department of nutritional sciences found that a specific combination of proven cholesterol-reducing foods, when consumed regularly, had as great an effect on cholesterol levels as statins.
Participants in the study followed a year-long seven-day menu that was low in saturated fats but rich in viscous fibre (a sticky, soluble sort of fibre found in oats, barley and other foods), soy protein, almonds and plant sterol-fortified margarine (such as Benecol and Flora Pro.active) — all foods confirmed as cholesterol-lowering in previous studies. Jenkins predicted a powerful “additive effect” might occur when these foods are combined because they have each been shown to lower cholesterol in different ways.
Indeed, 12 months later, those who strictly followed the portfolio eating plan lowered their LDL, or “bad” cholesterol, by 29 per cent. Taking a statin drug instead made only a marginal extra difference — cutting LDL by 30.9 per cent. The results “suggest that the average person can do a lot to improve their health through diet”, Jenkins says. Anne Denny, a nutrition scientist at the British Nutrition Foundation (BNF), describes the findings as “ impressive, particularly as it also seemed to raise ‘good’ or HDL cholesterol which has a protective effect” and “adding credence to the evidence that diet has a major role to play”. She suspects, however, that “adherence to the plan might be challenging for some people”, as it would involve a substantial shift in shopping patterns for regular meat and processed-food eaters.
Jenkins agrees that converting to the regimen may not be easy. It has been dubbed the “ape” or “gorilla” diet because of its high nut, seed and vegetable content. A typical dinner in the plan was tofu bake with aubergine, onions and sweet peppers, pearl barley and vegetables; participants reported that while it was easy to add single items, such as almonds, to their daily food intake, adjusting to an entirely new way of eating took effort.
“The fibre and vegetable protein were more challenging since they require more planning and preparation, and because these types of niche products are less available,” he says. “It’s just easier, for example, to buy a beefburger instead of one made from soy, although the range of options is improving. We considered it ideal if the participants were able to follow the diet three quarters of the time.” Still, even those who frequently “fell off the wagon” achieved at least a 10 per cent reduction in cholesterol levels by the end of the research.
According to Jenkins and his team, the beauty of the diet is that any element of it is better than nothing — so if all you can manage to change in your usual daily intake is a handful of almonds in place of a bag of crisps, then you are doing some good. It is designed to be adopted as a long-term shift towards a healthier eating plan, not a faddy, short-lived stab at lowering cholesterol. People who follow it stringently can expect to notice changes within a few months; for those who are less diligent, it might take longer. What’s more, because the diet is relatively low in calories and saturated fat, the researchers reported that many subjects claimed that they had to eat more food than usual to maintain their weight, making it a slimmer’s dream.
While advice about lowering cholesterol has remained constant over the years, this is the latest in a line of emerging research that has thrown new light on the best way to achieve it. Ellen Mason, a cardiac nurse for the British Heart Foundation, says: “Everybody needs some cholesterol because it is vital for functions such as transporting important acids to cells, but too many have raised levels that predispose us to a range of problems.”
Once it was thought that avoiding cholesterol in the diet was essential. Now scientists have shown that it is saturated fat that should be removed. For instance, a recent review in the BNF Bulletin found that eggs, which contain cholesterol, have an undeserved reputation as being problematic. Dr Bruce Griffin, of the centre for nutrition and food safety at the University of Surrey’s school of biomedical and molecular science, analysed 30 egg studies to discover that eggs “have no clinically significant impact” on cholesterol. People consuming one or more eggs a day were at no more risk of cardiovascular disease than non-egg eaters, he found. In the Toronto study, too, a control group who consumed a normal, low-fat diet, previously thought to be the heart-friendliest approach, lowered their cholesterol by only 8 per cent.
About two million people in England alone are prescribed cholesterol-lowering statin drugs and market analysts estimate the annual cost to the NHS is veering towards £500 million. But those figures are set to skyrocket. In January, the National Institute for Health and Clinical Excellence (NICE), the body that oversees NHS treatments, suggested that statins should be prescribed to anyone whose risk of developing heart disease in the following ten years is at least 20 per cent.
Previously only people considered to be at high risk of heart disease could be prescribed the drugs by their doctors, but the new ruling means a further 3.3 million people become eligible to take them. That doesn’t include statins bought over the counter. In 2004, the UK became the first country in the world to allow low-dose statins to be sold at pharmacies to anyone who scored more than 10 per cent risk of heart disease by filling in a questionnaire.
While there is no debating their effectiveness in lowering cholesterol — previous studies have demonstrated that they can reduce heart disease risk between 25 and 50 per cent — statins are far from being a magic wand that can be waved for a magically healthier life. “They have few side-effects — although muscle pain is fairly common,” says Mason. “But their use does need to be regulated as they work much better if combined with diet and exercise.” Last year, a team from America’s Centres for Disease Controls and Prevention looked at results from five separate national surveys between 1960 and 2002 and found a 3 per cent drop in cholesterol levels among men and women over 50.
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Statins, the study concluded, were the reason for this positive improvement. But analysing the results more closely, researchers found that levels of triglycerides, another threat to heart health and a possible indicator of obesity and inadequate exercise, had gone up. It appeared that people were continuing to guzzle high-fat foods and lead sedentary lifestyles, believing that statins would bear the brunt of their bad habits.
“Taking a pill may give people the false impression that they have nothing further to do to protect their health and prevent them from making serious lifestyle changes,” Jenkins says. “Emphasising diet changes in general can boost the success rate of statins while providing additional health benefits and a possible alternative for those for whom drugs are not a viable option.” He stresses, however, that his study was not intended to undermine the importance of the drugs in lowering cholesterol. “The benefit of statins to individuals at high risk of cardiovascular disease is not in question,” he says. “We don’t, however, know the long-term effects of these drugs when used on a large section of the broader population who are at low risk.”
His advice for anyone looking to lower their cholesterol is to “acquire a taste for tofu and oatmeal”. Denny agrees but stresses that “anyone who is taking statins on the advice of their GP should not just stop. As the latest study showed, the best approach for anyone at high risk of heart disease because of raised cholesterol is a combination of drugs, a good diet and working out.”
Create your own food prortfolio
The following four categories of food help to lower bad cholesterol according to the study in the AJCN:
Viscous fibre: A “sticky” type of soluble fibre found in porridge oats, barley, beans and certain vegetables such as okra and aubergine helps to bind the cholesterol in your digestive tract and sweep it out of your body. Including 10g of viscous fibre a day from foods such as porridge, bean-based soups and hoummos has been shown to decrease LDL cholesterol by about 5 per cent. On food packets look for “soluble fibre” content.
Soy protein: Tofu and soybean products contain virtually no saturated fat, but do provide protein, fibre, vitamins and minerals. Early studies showed that soy protein lowered cholesterol, although doubt has recently been cast on such claims. After reviewing more than 50 scientific studies, UK experts agreed that consuming 25g of soya protein daily (a glass of soy milk or some tofu), as part of a diet already low in saturated fat, may help to reduce the risk of heart disease. But the British Heart Foundation says that soy has only a minimal effect on lowering “bad” or LDL cholesterol and “has no significant effect on ‘good’ cholesterol, triglycerides and blood pressure. Therefore it is not recommended that people eat soya products alone to lower their cholesterol”. However, going meatless for some meals at least once a week is helpful because it means you are consuming fewer fatty foods.
Plant sterols: compounds found in most vegetables and fruits as well as popular products such as Benecol and Flora Pro-activ yoghurts, cheeses, margarines and desserts that are typically made from substances extracted from soybeans or certain vegetables. Because they are similar in structure to cholesterol, they “compete” for space in our intestines and less of the real cholesterol is absorbed. You need around 2g of plant sterols each day (the amount you would get if a plant sterol margarine were used on 3-5 slices of bread) to lower cholesterol by about 10 per cent over time. They need to be consumed regularly for the benefits to continue.
Nuts: Subjects in the study ate a handful of almonds each day, which provided cholesterol-lowering monounsaturated fat, plant sterols, fibre and vitamin E. Studies have shown that this sort of daily intake of almonds (around an ounce) lowered cholesterol by 4 per cent and those who ate two handfuls lowered it by 9 per cent. A variety of nuts is thought to be most beneficial and, as with the other foods, you would need to consume them regularly for results to be maintained.
A day on the diet
BREAKFAST
45g hot oat-bran cereal
A few blueberries
14 almonds
350ml soy drink (eg, soy milk)
1 slice oat-bran bread
2tsp Flora Pro.activ spread
Double fruit jam
LUNCH
300ml curried lentils (above)
METHOD
Heat a large non-stick pan and add 1tsp coriander powder, 1tsp cumin powder, 1tsp turmeric and 1tsp garam masala. Toast gently for a few minutes, without burning, until a strong aroma develops. Add 150g chopped tomato and stir well. Add 100g red lentils, one crushed garlic clove and one finely chopped red onion. Cover with water and bring to the boil. Simmer for 40min, stirring frequently and adding more water if it gets too thick. Scatter with coarsely chopped coriander leaves. Makes two servings.
SANDWICH
2 slices oat-bran bread
3tsp Flora Pro.activ spread
4 Soy Deli Slices
Lettuce, tomato and cucumber
SNACK
28 almonds
350ml soy drink
Fresh fruit
DINNER
Tofu bake with ratatouille
METHOD
Preheat oven to 180C. Coarsely chop half an aubergine, sprinkle with salt and place in a colander over a bowl for 30min. Cut 100g firm tofu into slices, and finely chop one red onion and one red pepper. Rinse the aubergine under cold running water until the salt has gone, mix everything together, add 150ml of water and bake for 40min. Serve with 40g cooked pearl barley, and vegetables (eg, broccoli and cauliflower).
SNACK
Fresh fruit
350ml soy drink
