Why you should pay attention to cholesterol early
There are, perhaps, not many other topics as prone to confusion as cholesterol. High? Low? Eggs? Bacon? Plant-based?
And, for women globally, heart disease is the leading cause of death (Roth 2020). While this may sound like super depressing news, on the flip side, there are modifiable risk factors that we have some agency over in order to take steps to protect our heart health.
Recognizing that this is a big topic, I’m going to assume that we accept causality between high LDL cholesterol and heart disease. It’s well established and part of the European consensus statement that the burden of cumulative LDL leads to the progression of heart disease (Ference 2017).
What I’d like to focus on is the idea of cholesterol years and specific dietary strategies that can be part of your preventative solution.
Cholesterol years
The best analogy to drive this point home is the risk around smoking which is usually calculated in “pack years.” How many packs did someone smoke (or is smoking) and for how long. These metrics then affect risk: more pack years, greater risk of lung cancer. Said another way, smoking 1 pack a week for 1 year is different from 1 pack a week for 10 years.
But, we rarely talk about cholesterol years even though the data shows that the longer we’re exposed to higher LDL, then the greater the risk of heart disease. Back in 2012, a study was done looking at people who had genetics that favored lower cholesterol levels. Then, they compared those people to those who had lower cholesterol using statin medications. They found two things (Ference 2012):
That those who had longer term low LDL had a significant relative risk reduction in heart disease (this was the genetically low group)
And their risk reduction was 3x greater compared to those who started taking a statin later in life
Let’s break this down in normal person speak.
For our purposes, let’s use LDL-C = 95 mg/dL. Usually, we’re shooting for LDL-C to be < 100 mg/dL for primary prevention, so this keeps us in range. Imagine our two people are both 55 years old.
Person A’s LDL cholesterol is 95 mg/dL because she’s been dealt a favorable genetic card where her cholesterol naturally sits in an ideal range.
Now, person B also has a LDL cholesterol that is 95 mg/dL. However, it’s at that level because she started medication at age 45 and it came down from 125 mg/dL. So, for person B, she had 10 years where we know she was sitting at a higher LDL level and even though it’s now lower and the same as person A, she’s had more cholesterol years under her belt….make sense?
Why does this matter?
Because we tend to think of cholesterol as a later in life issue rather than thinking about exposure over time. So, we’re likely missing windows of opportunity to take action earlier and reduce levels and reduce exposure time (Domanski 2020).
I caution against panicking, of course, but really good preventative medicine has these conversations early versus later because there’s lifestyle factors at play and knowing this allows you to assess risk, know your options, apply your own values and make deeply informed decisions about your health.
Hopefully, then we agree that action earlier versus later makes sense.
I want to review a simple and straightforward dietary strategy that you can have in your knowledge arsenal that is specific to lowering cholesterol (LDL-C). Know that there are other lifestyle factors like exercise, sleep, stress management, not smoking, weight, blood pressure and blood sugar, but I want to highlight one specific strategy, as to not be totally overwhelming!
The Portfolio Diet
The Portfolio diet was first introduced in the early 2000s as a dietary approach to lower LDL cholesterol. Reviews have been done since then to be sure that this strategy truly does lower LDL numbers and in 2018 authors concluded the dietary pattern lead to “clinically meaningful” improvements (Chiavaroli 2018). This is good! It’s one thing for things to improve labs, it’s another to be clinically meaningful–like you feel healthier and have less risk of heart disease.
It has 4 components:
42 g of nuts
50 g of plant protein from soy or pulses (legumes) like beans, peas, chickpeas or lentils
20 g of viscous fiber from oats, barley, psyllium, eggplant, okra, apples, oranges or berries
And 2 g of plant sterols (in the studies this was done as a margarine, but it can be found as a supplement. Ask your own healthcare practitioner!)
Ideally, this is done atop a healthy eating pattern which may be a Mediterranean diet, a traditional Japanese diet, Nordic diet, the DASH diet, to name a few. The terminology of Portfolio is borrowed from finance as a way to diversify your holdings. Each element contributes and if you do all 4 you have greater diversification of protection.
A reminder that this information is for education and always talk through what you learned with your own healthcare team.
Finally, so that you have some ideas of where to start, here are some ideas of recipes with nuts and others with legumes.
To a happy and healthy heart!
Dr. Antonella
References:
Chiavaroli, L., Nishi, S. K., Khan, T. A., Braunstein, C. R., Glenn, A. J., Mejia, S. B., … Sievenpiper, J. L. (2018). Portfolio Dietary Pattern and Cardiovascular Disease: A Systematic Review and Meta-analysis of Controlled Trials. Progress in Cardiovascular Diseases, 61(1), 43–53. https://doi.org/10.1016/j.pcad.2018.05.004
Domanski, M. J., Tian, X., Wu, C. O., Reis, J. P., Dey, A. K., Gu, Y., … Fuster, V. (2020). Time Course of LDL Cholesterol Exposure and Cardiovascular Disease Event Risk. Journal of the American College of Cardiology, 76(13), 1507–1516. https://doi.org/10.1016/j.jacc.2020.07.059
Ference, B. A., Ginsberg, H. N., Graham, I., Ray, K. K., Packard, C. J., Bruckert, E., … Catapano, A. L. (2017). Low-density lipoproteins cause atherosclerotic cardiovascular disease. 1. Evidence from genetic, epidemiologic, and clinical studies. A consensus statement from the European Atherosclerosis Society Consensus Panel. European Heart Journal, 38(32), 2459–2472. https://doi.org/10.1093/eurheartj/ehx144
Ference, B. A., Yoo, W., Alesh, I., Mahajan, N., Mirowska, K. K., Mewada, A., … Flack, J. M. (2012). Effect of Long-Term Exposure to Lower Low-Density Lipoprotein Cholesterol Beginning Early in Life on the Risk of Coronary Heart Disease A Mendelian Randomization Analysis. Journal of the American College of Cardiology, 60(25), 2631–2639. https://doi.org/10.1016/j.jacc.2012.09.017
Roth, G. A., Mensah, G. A., Johnson, C. O., Addolorato, G., Ammirati, E., Baddour, L. M., … Fuster, V. (2020). Global Burden of Cardiovascular Diseases and Risk Factors, 1990–2019 Update From the GBD 2019 Study. Journal of the American College of Cardiology, 76(25), 2982–3021. https://doi.org/10.1016/j.jacc.2020.11.010
