Hypercholesterolemia - Natural Treatments

Cholesterol is a waxy, fat-like substance that is mainly made within the body by the liver but also comes from food. Cholesterol is important for optimal health, as it is needed to make cell walls, tissues, vitamin D, hormones, and bile acid. Atherosclerosis refers to the narrowing of the arteries due to excess cholesterol forming plaques within the arteries, which leads to compromised blood flow. This compromised blood flow can cause a heart attack and increases the risk of blood clots, which can lead to a stroke.^[1] The current hypothesis of how atherosclerosis develops is called the response to injury hypothesis. It considers atherosclerosis to be a chronic inflammatory response of the arterial wall initiated by injury to the cells lining the interior of the arteries, also known as the endothelium. High blood lipid levels, high blood pressure, smoking, toxins, immune reactions, and inflammation can cause this injury. Over time, other cells build up in the area along with lipid debris, resulting in a plaque called an atheroma.^[2] Inflammation plays a significant role in the development of atherosclerosis, as inflammatory mediators influence many stages of atheroma development.^[3]

Cholesterol is found in the blood, attached to lipoproteins for transport, and within the cells.^[1] The main categories of lipoproteins are very-low-density lipoprotein (VLDL), lowdensity lipoprotein (LDL), and high-density lipoprotein (HDL). VLDL and LDL transport fats, in the form of triglycerides and cholesterol, from the liver to the body cells. These lipoproteins are associated with an increased risk of heart disease due to their role in the development of atherosclerosis. HDL returns fats to the liver, and elevations in this lipoprotein are associated with a low risk of heart attacks. LDL cholesterol is often referred to as “bad cholesterol”, while HDL is referred to as “good cholesterol”; however, we need both in appropriate levels. Triglycerides are an important risk factor for cardiovascular disease, especially if high levels are found in addition to low HDL levels.^[4] “Hypercholesterolemia” is a term used when someone has high cholesterol. High cholesterol and triglycerides can be genetically linked, but there are many potential causes of these elevations. As you age, the LDL receptors are damaged, but this damage is accelerated in various diseases, such as diabetes. A diet high in saturated fat and cholesterol decreases the number of LDL receptors, which reduces the feedback mechanism that tells the liver that no more cholesterol is necessary and therefore leads to higher cholesterol levels.^[3]

Pharmaceutical Treatment

Competitive Inhibitors of HMG-CoA Reductase, aka “Statins”
“Statins” block a key step in the formation of cholesterol.^[5] They are the best-tolerated and most effective pharmaceutical intervention to reduce LDL, and are considered a first-line medication. Their effect depends on dose and should be used in the lowest dose possible, due to their adverse-effect profile.^[6]

Fibrates
Fibrates decrease levels of VLDL and sometimes LDL since they increase the breakdown of lipoprotein triglycerides.^[5] They are most useful in people with very high triglyceride levels and can be used as an adjunctive therapy alongside a “statin”.^[6]

Bile Acid–Binding Resins
Bile acid–binding resins are used in people who only have high levels of LDL and no other elevated markers. They bind bile acids in the intestine and prevent their reabsorption.^[5]

Naturopathic Approaches

Diet and Exercise
The Mediterranean diet has been widely studied as a dietary intervention for coronary artery disease.^[2] Following the Mediterranean diet reduces inflammation even if weight loss doesn’t occur. However, if weight loss and loss of waist circumference occur, inflammatory markers are further reduced.^[7] A three-month study showed a 15% reduction in cardiovascular disease risk with the diet, and another study reported a 50–70% reduction of the risk of recurrence in coronary heart disease patients after four years of follow-up. The Portfolio diet is based on the Mediterranean diet but involves the inclusion of specific foods known to lower cholesterol (see Table 1, next page). One study showed there was no significant difference between the Portfolio diet and “statin” therapy in lowering cholesterol and reducing C-reactive protein (CRP), a marker of inflammation.^[8] Regular exercise lowers cholesterol, increases heart muscle strength (which improves the volume of blood it can move), improves blood supply (thereby oxygen to the heart), reduces blood pressure, inhibits blood clots, minimizes damage due to stress, and reduces overall body fat.^[4]

Table 1. Mediterranean Diet

Nuts
Nuts are often perceived as unhealthy due to their high fat content; however, they can benefit health and lipid levels.^{[9, 11]} Nuts are a great source of omega-3 polyunsaturated fat, fiber, plant sterols, and flavonoids.^[3] It has been shown that people who consume higher amounts of nuts and seeds have significantly reduced risk for cardiovascular disease (CVD). Changing your fat source from meat and dairy products to nuts and seeds has been shown to reduce heart disease by 45%. Nuts are a rich source of arginine, which is a precursor for nitric oxide, which causes vasodilation and therefore may help improve blood flow and fluidity and reduce clot formation. Walnuts are one of the best nuts to consume, since they are also rich in antioxidants and alpha-linolenic acid. People with high cholesterol had a 4–5% decrease in total cholesterol after consuming 50–55 g of walnuts per day. Eating approximately thirty hazelnuts per day can reduce VLDL cholesterol and triglycerides, with small reductions in total cholesterol and LDL-C and increased HDL-C. Consuming between 50 and 100 g of nuts at least five times a week as part of a healthy diet, with at least 35% total fat, can decrease total cholesterol 2–16% and LDL-C 2–19% in people with normal and elevated lipid levels. It is important to note that these changes can occur without weight gain.^{[9, 10]}

Plant Sterols and Stanols
Phytosterols and stanols are structurally similar to cholesterol and reduce cholesterol absorption by displacing cholesterol. They can be found in small amounts in many grains, vegetables, fruits, legumes, nuts, and seeds. Increased intake of phytosterols/ stanols reduces the intestinal absorption of dietary and biliary cholesterol, and therefore significantly decreases LDL-C.^[9] One study showed that consuming 2 g of plant sterols reduces the concentration of LDL-C in individuals with hypercholesterolemia by more than 10% after 12 months.^[11] Plant sterols/stanols also have a beneficial effect on HDL-C and triglycerides.^[12] Supplementation can be an effective way to ensure adequate consumption of plant sterol/stanols. One study showed that supplementing 1.8 g of esterified plant sterols/stanols in soft gel capsules daily was shown to be effective in lowering cholesterol.^[13]

Fiber
Dietary fiber is a safe and practical approach for cholesterol reduction. Soluble fibers include beta-glucan from oats, pectins from apples, and fibers from flaxseed and psyllium. Dietary fibers are bile acid sequestrants, which means they bind to bile acids and prevent their reabsorption. They upregulate LDLR, increase clearance of LDL, inhibit hepatic fatty acid synthesis, reduce absorption of macronutrients, improve intestinal motility, improve insulin sensitivity, and increase satiety with lower food consumption. They reduce total cholesterol by 1.75 mg/dL per 1 g of intake and reduce LDL-C 2.2 mg/dL per 1 g of intake.^[14] Psyllium is the most effective soluble fiber in treating hypercholesterolemia. It decreases LDL-C while insignificantly reducing HDL-C.^[9] Oat bran is one of the most popular fiber sources for the reduction of cholesterol. Consuming about 50–100 g of oat bran daily can reduce total cholesterol by about 20%. Oatmeal is said to have similar cholesterol-lowering effects despite having less fiber, because it is higher in polyunsaturated fatty acids. It is recommended to consume at least 35 g of fiber daily from fiber-rich foods in order to reduce cholesterol levels and reduce inflammatory mediators such as CRP.^[3]

Essential Fatty Acids
Monounsaturated fatty acids, found in olive oil, avocado, and nuts lower LDL and can raise HDL. Polyunsaturated fatty acids or omega-3 fatty acids are good at lowering triglycerides and reducing the risk of heart disease. Omega-3 fatty acids have beneficial effects on atherosclerosis, inflammation, endothelial function, blood pressure, and triglycerides.^[15] Sources of omega-3 fatty acids include cold-water fish, nuts, vegetables, and flaxseed. Eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA) are components of omega-3 fatty acids found in fish. Supplementation with EPA and DHA has minimal effect on cholesterol levels, with it increasing LDL-C and HDL-C slightly, but it does lower triglyceride levels significantly. In addition, it improves endothelial function and arterial flexibility, improves blood and oxygen supply to the heart, reduces platelet aggregation, and has a mild hypotensive effect via vasodilation and the promotion of sodium excretion.^[3]

Niacin
High-dose niacin is effective in lowering LDL cholesterol, Lp(a), triglycerides, CRP, and fibrinogen levels, while raising HDL cholesterol. Despite the benefits of niacin, it is often underutilized due to the skin-flushing side effect that occurs when it is taken.^[3] It can raise homocysteine, and therefore should be taken with other B vitamins.^[15]

Garlic
Garlic plays an important protective role against heart disease and stroke, due to its ability to affect the development of atherosclerosis and lower LDL cholesterol. Garlic is able to increase HDL cholesterol and has the added benefit of reducing triglycerides. Garlic also lowers blood pressure; inhibits platelet aggregation; promotes fibrinolysis; reduces plasma viscosity; prevents LDL oxidation; and exerts positive effects on endothelial function, vascular reactivity, and peripheral blood flow.^[3] Allicin is the key compound within garlic that gives it its pharmacological effects. Garlic has been shown to modestly improve total cholesterol, LDL, and triglycerides levels. Despite numerous positive studies, the mechanism of action is not clear at this time. Daily consumption of one half to one clove of garlic may decrease total cholesterol by 5–9%, while extracts and dried garlic powder similarly reduce cholesterol by 2–6%. The most dramatic effects were seen with long-term intervention and higher-baseline total cholesterol levels.

Conclusion

In conclusion, hypercholesterolemia is complex and can be prevented and treated with lifestyle changes, such as increasing exercise and changing the diet. If needed, natural products can be used as treatment before initiating pharmaceuticals, given their safety profile and low risk of adverse effects. It is important to remember to address inflammation and liver function when treating hypercholesterolemia, as they are fundamental in the formation of atherosclerosis and cholesterol production, respectively. The list of natural interventions for hypercholesterolemia mentioned in this article is not comprehensive; therefore, it is recommended to consult a health-care provider trained in natural medicine for proper dosing and to determine which interventions are appropriate.