So many people are told that if their good cholesterol number is outstanding (HDL of 60 or higher), it mitigates the fact that their LDL (bad cholesterol) is high. My answer to this is “Do you know why there are no support groups for women and men who have suffered from sudden cardiac death?” In the United States 200,000 people die each year from sudden cardiac death.
I’m not trying to be shocking here, just honest. Cardiovascular disease (CVD) has been the top killer of men and women for the last 100-plus years, and LDL is the most dangerous type of cholesterol.
Yet people are just supposed to ignore their bad LDL levels? Approximately 150,000 people ages 65 or younger died last year from cardiovascular disease, and more women are dying of it now compared to men. Many major clinical trials have proven that a high HDL level is not enough to counteract high LDLs. All of your cholesterol numbers need to be normal or low (except HDL, of course, which should be high).
And a favorable cholesterol ratio (total cholesterol divided by your HDL) doesn’t warrant accepting an abnormal LDL either. Do you want to go up against the number one killer in the United States without maximizing your odds? The price for being wrong about HDL versus LDL is too great and too permanent, so I’m going to err on the side of living! Okay, now I’ll get off my soapbox.
What is High Cholesterol?
High or unhealthy cholesterol can be manifested in high levels of LDL (bad cholesterol), high levels of triglycerides (this is a measure of fat in the blood), or low HDL (good cholesterol).
They’re all risk factors for cardiovascular disease, either by themselves or in combination. In Dr. Moyad’s world, LDLs of 100 mg/dL or higher are too high, triglycerides of 100 mg/dL or higher are too high, and HDLs of less than 40 mg/dL in men and less than 50 in women are too low!
Cholesterol lays the foundation for our hormonal house, if you will. We need it to make estrogen, testosterone, and even vitamin D (which acts like a hormone). It’s also a key component of cells. But too much of it starts to clog the pipes. LDLs are stickier inside those pipes than triglycerides, which makes them more dangerous (HDLs remove blockages in the blood and send cholesterol back to the liver).
While there are usually no symptoms of CVD until you have a cardiovascular event (usually a heart attack or stroke), there are some subtle tip-offs that something abnormal may be going on, such as sexual dys-function, especially in younger men and women. Lowering your cholesterol keeps all of your pipes clean, including your sexual pipes, and it also reduces the risk of high blood pressure and blood clots.
Simple cholesterol testing is a wonderful way to see where you stand. However, since half of first-time heart attack patients have normal cholesterol, another blood test that every person reading this section should ask their doctors about is the hs-CRP or high-sensitivity C-reactive protein blood test (it is also known as cardiac CRP or cardiac hs-CRP). It’s a measure of inflammation in your body, including in your arteries, which can lead to clots and heart attacks.
An hs-CRP of below 1 mg/L is ideal, 1 to 2 mg/L is moderate, and above 2 is too high! (If you have a bad case of arthritis or the flu, the test can be artificially high. If you’re on immunosuppressive medications, such as steroids, it might not be a good idea to get this test either because it could be artificially low.)
Of course, there are many cholesterol-lowering medications, called statins, on the market, but they come with potential side effects, so you want to do everything possible to take the lowest dose available (see “What Else Do I Need to Know?”).
I believe long-term use of statins at high doses can slightly increase the risk of all kinds of problems, from type 2 diabetes to memory loss and even sexual problems. But moderate or lower statin doses—combined with lifestyle changes, especially diet and exercise—are unparalleled in helping prevent disease (including brain, eye, and heart disease and certain cancers). Not to mention, 10 to 20 percent of people cannot tolerate statins, so they need other options, such as dietary supplements.
Home Remedies For High Cholesterol
1. Red yeast rice 600 to 3,600 milligrams a day in divided doses (usually 1,200 to 2,400 milligrams total)
This extract is a traditional Chinese herbal medicine that was first mentioned in AD 800 as a way to improve blood circulation. It’s produced by the fermentation of a fungal strain called Monascus purpureus (red yeast) over moist and sterile rice.
Red yeast rice (RYR) has a vibrant and distinct red color, flavor, and aroma, so it’s also used as a flavoring agent in a number of Chinese dishes and for brewing red rice wine. In the late 1970s, Dr. Akira Endo (one of my research heroes) discovered that a Monascus yeast strain naturally produced a substance that inhibits cholesterol synthesis in the liver, and he named it monacolin K. Researchers were later able to isolate the compound, which has the same structure as lovastatin, the first prescription statin.
So RYR was the first true statin used in medical history! In fact, three of the original statins prescribed in the United States were derived from fungi (lovastatin, pravastatin, and simvastatin). RYR contains at least 10 different compounds known as monacolins, and some of them have the ability to block the same enzyme in the liver that prescription statins do. Of all the monacolins that have been isolated so far, monacolin K is the most potent, and it’s the one that is primarily responsible for RYR’s ability to lower LDL cholesterol.
There have been more than 100 clinical trials with RYR, and many cardiologists now routinely recommend it for people who cannot tolerate statins. A meta-analysis of 9,625 patients in 93 randomized trials involving three different commercial variants of RYR found a mean reduction in total cholesterol (-35mg/dL), LDLs (-28 mg/dL), and triglycerides (-36 mg/dL) and an increase in HDLs (+6 mg/dL). The largest, randomized, placebo-controlled clinical trial, the China
Coronary Secondary Prevention Study, evaluated a RYR product called Xuezhikang.
Participants included 4,870 people (3,986 men, 884 women) with a history of heart attack. They took 600 milligrams of RYR twice daily (1,200 milligrams total with a monacolin K content of 2.5 to 3.2 milligrams per capsule) or a placebo and were followed for 4.5 years. Levels of LDL dropped by 18 percent on average, triglycerides went down 15 percent, and HDL increased by 4 percent.
Ideally, you want to find a RYR product that has at least 2.5 milligrams of monacolin K in each 600-milligram capsule. RYR works as well as the lowest doses of low-cost statins, but you have to take more pills to get to that potency. For example, you usually take one statin pill per day (1 to 10 milligrams). However, it can take anywhere from one to six RYR pills (assuming each is 600 milligrams) to achieve a similar result.
But here’s the frustrating thing about RYR: Dietary supplement companies are actually legally prohibited from standardizing the amount of monacolin K in their products (meaning the amount of active ingredient is not guaranteed)!
Because RYR works too much like prescription statins, supplement companies can get in trouble for selling an over-the-counter product that acts too much like a drug. This is one of the dumbest penalties against dietary supplement companies that I have ever witnessed. Either the supplement should be banned entirely from the United States or companies should be able to standardize the monacolin K amount in red yeast rice!
Because companies can’t reveal the amount of active ingredient in their products, you may have to test different brands to see which ones have enough to make a difference. However, many RYR companies in the United States and even globally tend to make products that contain enough monacolin K to reduce LDL.
The other issue is that some products might contain a potentially harmful by-product of yeast fermentation known as citrinin (it can damage the kidneys and other organs). Check with the company to make sure there is no citrinin in the product; companies are allowed to test for this and report it to the consumer (gee, thanks!). So, this all means you have to put in some effort to find a good RYR product. The potential benefits are worth your time, though.
Note: Do not take RYR if you have liver or kidney impairment or allergies to yeast or fungus. Take it with or after meals for better absorption, but don’t take it with pectin or oat bran; these high-fiber products specifically reduce absorption. Finally, grapefruit juice can interact with RYR just like it can with the cholesterol drug lovastatin (as well as at least two other cholesterol-lowering drugs), so don’t drink it while you’re taking RYR.
2. Soluble fiber (especially psyllium, but also glucomannan, inulin, pectin, guar gum, oat beta-glucan, and barley beta-glucan) dosage varies
Soluble (viscous) fiber lowers LDL cholesterol in multiple ways. When it reaches the small intestine, fiber can prevent bile salts from being reabsorbed, which essentially prompts the liver to break down more cholesterol to make more bile salts. (The liver makes bile salts from cholesterol, and the gallbladder releases them into the intestines during digestion to break up fat.) Fiber also keeps sugar from being rapidly absorbed. As a result, less insulin gets released (insulin stimulates the liver to increase cholesterol production, so less of it means less cholesterol). Finally, soluble fiber is a prebiotic, so it feeds good bugs in the gut, which leads to less cholesterol (and bile acid) absorption.
Soluble fiber supplements, primarily psyllium powder, have been studied the most in clinical trials, and at 10 to 15 grams per day (divided into two daily doses), they can lower LDL as much as a low-dose cholesterol drug. Consuming 10 grams of psyllium daily on average lowers LDL by about 7 percent, and in some people slightly higher doses (up to 15 grams) can reduce LDL by 15 to 20 percent. If you’re frequently constipated or have poor blood sugar control, then you’ll doubly appreciate fiber. Still, it’s rarely necessary to take more than 10 grams a day, and higher doses increase the risk of side effects, such as bloating and gas.
In my opinion, inexpensive dietary fibers in powder form (2 to 3 tablespoons in water equals 5 to 10 grams of soluble fiber) are actually easier to take than fiber pills, where in many cases it takes six capsules to get 3 grams of fiber, meaning you’d have to take 12 to 18 capsules per day just to match 2 to 3 tablespoons of the powder. Another choice is to try a food product that has 10 to 15 grams of fiber (insoluble and soluble), such as bran cereals, to see if you get the same result.
Other soluble fibers—including guar gum and pectin supplements (10 to 15 grams per day), concentrated oat and barley beta-glucan (5 grams daily), and glucomannan (3,000 to 4,000 milligrams per day)—can also lower LDLs. Do not expect any change in HDLs with fiber, and only expect a drop in triglycerides and inflammatory markers, such as hs-CRP, if you also lose weight on your fiber program. You can expect to see results with daily soluble fiber supplementation in as little as 2 to 4 weeks!
3. Phytosterols (plant sterols and stanols) 2,000 milligrams a day
Phytosterols block the uptake of cholesterol from food and bile sources in the intestinal tract. They reduce LDLs, but don’t really impact HDLs and triglycerides. This blockage of cholesterol absorption is followed by an upregulation of LDL receptors in the liver, meaning the liver removes more LDL from the blood, which can also reduce inflammation (so you could say they provide an LDL “twofer”).
Phytosterol supplements are really just less potent copycats of the drug ezetimibe (Zetia), which can reduce LDLs by approximately 20 percent (at a 10- milligram dose). At 2,000 milligrams per day, phytosterols have been shown to reduce LDLs by an average of 10 to 11 percent. This has prompted many food manufacturers to add them to their products, including yogurt, margarine, orange juice, mayonnaise, olive oil, and milk. You can get the 2,000-milligram dose by taking one or two caplets twice daily with a glass of water right before your two largest meals (to help block cholesterol absorption). Note: Phytosterols may reduce the absorption of some fat-soluble vitamins, so you need to take a multivitamin daily as well.
4. Pantethine (a derivative of vitamin B5)
Pantethine (a derivative of vitamin B5) is metabolized by the body from pantothenic acid (vitamin B5). It can block an enzyme in the liver that’s used to make cholesterol, and it can also slightly thin the blood.
In one study, Japanese researchers gave participants 600 milligrams of pantethine per day (in three divided doses) over 16 weeks and found that it lowered LDLs by 15 percent and triglycerides by 14 percent and increased HDLs by 17 percent. However, the same impressive results haven’t been seen in American studies yet (with 600 to 900 milligrams per day); this is partly because participants in the US studies had good cholesterol levels to begin with (LDL was already in the low 100s) and were on aggressive cholesterol-lowering diets. About 1 to 2 percent of participants complained of GI issues, such as stomach upset.
Overall, this vitamin derivative has a good safety record and appears to cause a small drop in LDL cholesterol (4 percent in the American studies), but I want to see more studies that it reduces the risk of heart attack and stroke before recommending it over any of my top three!
What Supplements Are Useless For High Cholesterol?
Fish oil to lower LDL
Let me repeat, if you’re trying to lower LDL, high doses of fish oil can increase it, so talk with your doctor about your specific cholesterol-lowering strategy.
It’s trendy to be vitamin D-deficient these days, but correcting this deficiency does not change cholesterol levels. So, how is it that research suggests higher blood levels of D may be associated with a lower risk of cardiovascular disease? Vitamin D blood levels may simply be a marker of healthy behavior.
A lean man or woman with low cholesterol who consumes fish and exercises regularly is more likely to have a higher blood level of vitamin D compared to a physically inactive, overweight or obese man or woman with high cholesterol and other heart-unhealthy factors. That doesn’t mean that taking D will help you lose weight or improve your lipid profile.
At medical meetings, I like to remind health care professionals that it’s more important to raise vitamin D levels naturally through weight loss, exercise, and diet (yes, these things can increase vitamin D!) before starting a massive supplementation effort. I think if someone has superlow vitamin D blood levels (in the single digits, like 1 to 9 ng/mL), which is rare, supplementing might slightly improve heart health by reducing blood pressure.
There is a clinical trial going on in the United States (known as VITAL) to determine if vitamin D or fish oil really improves heart health. I believe the results will show that vitamin D supplements by themselves have minimal to no cardiovascular benefits, but I hope I’m wrong.
No-flush niacin (inositol hexaniacinate) or even regular niacin
Niacin (both supplements and the prescription form) may help lower triglycerides but not LDLs, and it comes with significant side effects, including facial flushing, liver toxicity, and stomach upset or ulcers. The latest evidence shows that it might not be as clinically effective as once thought for reducing heart attack and stroke. What’s more, adding niacin to your regimen to lower your statin dose is very dangerous and can increase liver toxicity. Then there’s no-flush niacin (inositol hexaniacinate), which does not cause the telltale facial flushing that regular niacin does, but it doesn’t work for reducing triglycerides or LDL. No flush = no work! Also, sustained or slow-release over-the-counter niacin can cause liver damage. To sum it up, current research is casting doubt on the benefits of taking niacin in any form.
Guggulipid or guggul
The herbal extract guggulipid has been used for years in Asia as a cholesterol-lowering agent, and its popularity seems to be increasing in the United States. One of the best clinical trials of this supplement, published in the Journal of the American Medical Association way back in 2003, tested two different doses of standardized guggul extract (guggulipid, containing 2.5
percent guggulsterones; I swear to you I am not making up these words) and found that they did not work as well as a placebo at reducing cholesterol in healthy adults with high cholesterol who ate a typical Western diet. It was generally well tolerated, but six patients in the supplement group developed a hypersensitivity rash versus none in the placebo group. I say skip it.
Policosanol is a natural compound that comes primarily from sugar cane wax, but it’s also in beeswax, rice bran, and wheat germ. It’s sold in more than 40 countries as a cholesterol-lowering agent, but almost all of the research supporting the benefits of policosanol came from a single research center in Cuba. After multiple clinical trials in the United States and Europe, it appears to work about as well as a placebo, which is exactly my experience with this supplement.
You can find garlic supplements in a variety of forms, including dehydrated powder, aged extract, steam-distilled oil, ether-extracted essential oil, and oil macerate. Regardless of the type, they just don’t work well enough to recommend them. In a research review of 29 clinical trials, garlic had no impact on LDL or HDL and lowered triglycerides only a small amount. Another review of studies showed no impact on any type of cholesterol.
Finally, higher doses of garlic or supplements increase the risk of bad breath, body odor, and gastrointestinal side effects. It also has the potential to interact with blood-thinning drugs, like warfarin. It’s not worth it.
Green tea catechins (extract of green tea)
A review of 14 randomized trials with more than 1,130 participants that was published in the American Journal of Clinical Nutrition demonstrated that green tea beverages or extracts lower LDL by one to two points. In another study, published in the Journal of the American College of Nutrition (both highly reputable journals, by the way), doses of 145 to 3,000 milligrams per day over 3 to 24 weeks reduced LDL by only five points on average! This shows you how weak this supplement is and how little it impacts LDL. The really large dosages potentially needed compared to the availability of other more effective options make it a dog (I mean a bad dog—stay away).
B6, B12, and folic acid
This one’s a little tricky: These B vitamins have been shown to lower blood levels of a compound known as homocysteine, which has been associated with an increased risk of heart disease. However, studies haven’t found that reducing homocysteine levels results in a reduced risk of heart disease. This is just another example of how altering something that’s potentially harmful in the body doesn’t mean squat until you can actually demonstrate that it reduces the risk of disease or dying. Regardless, what has been proven is that these supplements do not change any cholesterol levels.
Artichoke leaf extract
This plant was supposed to impact one part of the cholesterol pathway, but the results have been weak and the dosage needed is high. Don’t waste your money.
What Supplements Are For Kids to Treat High Cholesterol?
A unique study of children (ages 8 to 16) who were genetically predisposed to having high cholesterol found that a RYR supplement reduced LDL by 25 percent. There were no adverse events in terms of liver or muscle enzyme abnormalities over the 8-week treatment period, so speak with your doctor if you know your child has a risk factor for high cholesterol.
What Lifestyle Changes Can Help With High Cholesterol?
Move more, and more often
Exercising regularly while on a statin or another cholesterol-lowering product can reduce the risk of dying from all causes by another 70 percent! Yet exercise acts like one of those drugs that only stays in the body for a short time, so you have to keep doing it. If you exercise daily or every other day, your HDLs will rise, but if you take many days or even a week off, they’ll drop.
Watch your diet
A low-fat (especially saturated fat) or, more importantly, a reduced-calorie diet can reduce LDLs as much as a low-dose prescription drug. And a low-carbohydrate diet can reduce triglycerides and LDLs as much as a low-dose prescription drug. Basically, it’s very easy to get a 5 to 10 percent reduction in cholesterol by following a Mediterranean diet or similar plan. It’s not unusual to see people who’ve shaved 50 to 100 points from their triglyceride levels or reduced or eliminated their statin pills after losing several inches from their waists through exercise and a low-carb diet.
Research has shown that eating 25 grams a day of soy protein might reduce LDLs by 1 to 5 percent (up to 8 to 10 points), but I believe getting concentrated protein from a variety of sources (whey, egg white, pea, or brown rice) can also do this. Increasing your protein consumption and reducing your carbohydrates can lower LDL and perhaps even triglycerides.
I’m not advocating starting to drink if you don’t do it currently, but alcohol in moderation (one drink a day for women and one or two for men) can slightly increase good cholesterol; it also works like a mini-aspirin to thin the blood.
However, many people have trouble with the moderation part. A new report from the Centers for Disease Control and Prevention suggests that men in the United States now drink as many as 150 calories of alcohol per day, on average, and women down as many as 50 to 75 calories on average. The weight gain from alcohol can raise triglyceride levels (in addition to leading to other health problems), so keep it in check.
What Else to Know About High Cholesterol?
Statins have been the target of recent scrutiny, but don’t buy into the negativity. Statins and other cholesterol-lowering drugs have been responsible for huge reductions in the number of cardiovascular procedures, such as bypass surgery and angioplasties, in my lifetime. They have saved billions of dollars in health care costs, and now they are even cheaper than most supplements. Above is a table of currently available statins and the minimum dose needed to reduce LDL cholesterol by at least 30 to 40 percent.
Researchers have found multiple benefits from cholesterol-lowering drugs, probably because they reduce some inflammatory markers and growth factors that can lead to or exacerbate other diseases or conditions. Cholesterol-lowering drugs and supplements are currently being studied for Alzheimer’s, autoimmune diseases (including multiple sclerosis), colon cancer, erectile and female sexual dysfunction, eye diseases, and prostate cancer.